Treatment providers should discuss detoxification settings and
patient matching within the context of two fundamental principles of
high-quality patient care. The first is that the patient's needs should
drive the selection of the most appropriate setting. The severity of
the patient's withdrawal symptoms and the intensity of care required to
ensure appropriate management of these symptoms are of primary
importance.
Second, detoxification should be viewed as the gateway to ongoing
treatment. As noted in Chapter 1 of this Treatment
Improvement Protocol (TIP), providing a safe withdrawal is the first
goal of detoxification, and another is to prepare the patient for
appropriate followup treatment. Staff members in all detoxification
settings, from the least restrictive to the most intensive, must
facilitate this goal, as should policies governing reimbursement for
services.
Insurance carriers' and managed health care organizations' goal of
short-term cost savings is having a significant effect on the selection
of the treatment settings. Insurance providers have developed and
implemented stringent policies concerning reimbursement for alcohol and
other drug (AOD) detoxification services. Such policies govern not only
the setting in which the services are provided, but also the maximum
number and length of detoxification episodes covered.
Insurers are increasingly reluctant to cover inpatient detoxification
unless there is clear-cut medical or psychiatric evidence of the
patient's need for this kind of care. They have established medical
criteria, such as the severity of AOD dependence and the presence of
concurrent medical complications, upon which to base the decision to
provide coverage. Insurers may also tie reimbursement of detoxification
programs to their structures. For example, services that are offered by
social model programs may not be covered if the program has no formal
affiliation with a physician.
Current policies concerning reimbursement for services may be
problematic from a patient care perspective. They give insufficient
weight to the variety of factors that affect the selection of a setting
in which the patient has the greatest likelihood of achieving
satisfactory detoxification. Some persons in need of detoxification,
for example, may not be appropriate candidates for outpatient
detoxification because their spouses or others in their household are
AOD dependent. These individuals may be more appropriately treated if
they undergo detoxification in a residential setting such as a recovery
house or other AOD-free residential environment. Detoxification is
ultimately cost effective only if it is appropriate to the needs of the
individual patient.
Considerable variation exists in the levels of care provided by AOD
abuse treatment programs. Inpatient programs generally have fairly
extensive onsite capabilities for providing medical care to patients or
are affiliated with a nearby medical center. Some residential treatment
programs are loosely affiliated with a medical center. Intensive
outpatient treatment programs may be located within or closely
affiliated with a hospital or medical center. Therapeutic communities
are residential and have minimal, if any, onsite medical capabilities.
They tend to rely on outside sources of medical care. Detoxification
services generally are available under a medical model or a social
model.
Medical model programs are directed by a physician and staffed by
other health care personnel. They range from hospital-based inpatient
programs to free-standing medically based residential programs in
hospitals or in community facilities that can draw on various medical
resources.
Social model AOD abuse treatment programs concentrate on providing
psychosocial services. Social workers and other clinicians provide
services such as individual and family counseling and coordination of
care. Patients who need a physician's care may be referred to a nearby
emergency department, which is not a cost-effective source of
detoxification services. Some programs that provide detoxification
services have a physician on call who can prescribe detoxification
medications.
Social model programs use a variety of approaches to detoxification,
but the emphasis is most often on nonpharmacological management of
withdrawal. Usually, counselors do not have prescribing privileges and
cannot legally administer medications from stock bottles to patients.
In some programs, counselors can assist patients in taking
detoxification medications. The patient's medication supply must be in
a container that is labeled with the patient's name and that includes
instructions for taking the medication. Counselors observe the patient
take the medication, and they maintain a log. Counselors can also
monitor patients' symptoms and call physicians or nurse practitioners if
patients become ill.
Social model programs should not provide detoxification for people
who have severe dependence on alcohol or other sedative-hypnotics, as
withdrawal can be life threatening in these cases. Patients must be
properly medically evaluated when they enter a social model program.
Detoxification may occur either in an inpatient or an
outpatient setting. Both types of settings initiate recovery
programs that may include referrals for problems such as medical, legal,
psychiatric, and family issues.
According to Alling(1992), inpatient
detoxification has the following advantages:
"The patient is in a protected setting where access to
substances of abuse is restricted.
"The withdrawal process may be safer, especially if the patient is
dependent upon high levels of sedative-hypnotic drugs, since the
clinician can observe him or her closely for serious withdrawal
symptoms, and medications can be adjusted.
"Detoxification can be accomplished more rapidly than it can in an
outpatient setting."
Outpatient detoxification has the following advantages:
"It is much less expensive than inpatient treatment.
"The patient's life is not as disrupted as it is during inpatient
treatment.
"The patient does not undergo the abrupt transition from a protected
inpatient setting to the everyday home and work settings."
Many acute are hospitals formerly operated subacute-care units, or
chemical dependency units, that served as sites for uncomplicated
detoxification. These programs, known as Minnesota Model programs,
generally involved a 28-day inpatient stay followed by varying lengths
of outpatient therapy and participation in self-help groups. Most were
based on the Alcoholics Anonymous (12-step) model of personal change and
the belief that vulnerability to AOD dependence is permanent but
controllable. The goals of these programs were abstinence from all AODs
and lifestyle alteration. Because of decreasing insurance reimbursement
for stays in such units, many have ceased operation. In an effort to
maintain treatment for those who need this type of care, some of the
hospitals that house these units have developed other addiction
services, such as intensive outpatient treatment programs.
Many acute care hospitals that do not maintain chemical dependency
units commonly use a "scatter bed" approach, placing a patient in any
clinical area of the hospital in which a bed is available Alling(1992), inpatient
detoxification has the following advantages:
"The patient is in a protected setting where access to
substances of abuse is restricted.
"The withdrawal process may be safer, especially if the patient is
dependent upon high levels of sedative-hypnotic drugs, since the
clinician can observe him or her closely for serious withdrawal
symptoms, and medications can be adjusted.
"Detoxification can be accomplished more rapidly than it can in an
outpatient setting."
Outpatient detoxification has the following advantages:
"It is much less expensive than inpatient treatment.
"The patient's life is not as disrupted as it is during inpatient (Alling, 1992).
Psychiatric hospitals occupy an important niche in the spectrum of
detoxification settings because they are the preferred settings for
patients who are psychotic, suicidal, or homicidal. In areas where
medical hospital detoxification programs are not available, patients
with no psychiatric comorbid conditions may be admitted to a psychiatric
unit for detoxification. The detoxification protocols used in
psychiatric hospitals are the same as those used in medical acute and
subacute settings.
Rather than acute care hospitals, medically managed residential
treatment centers are AOD abuse medical care centers, where specialized
services are provided by medical staff under the direction of a
qualified physician with knowledge of and skills in addiction treatment.
Psychosocial and behavioral services are usually provided as necessary
components of successful treatment.
Psychiatric hospitals occupy an
important niche in the spectrum of detoxification settings because they
are the preferred settings for patients who are psychotic, suicidal, or
homicidal.
Again, outpatient detoxification has three major advantages: It is
less expensive; it is less disruptive; and it allows the patient to
remain in the same setting where he or she will function when drug free.
Outpatient detoxification usually is offered in community mental health
centers, AOD abuse treatment clinics, and private clinics.
Emergency Departments. The emergency department (ED) often
serves as a gateway to AOD detoxification services. AOD detoxification
programs may rely on emergency department staff to assess and initiate
treatment for patients with medical conditions or medical complications
that occur during detoxification. For social model programs, EDs are
often a safety net for patients who need medical treatment. For the AOD
abuser who has overdosed or who is experiencing a medical complication
of AOD abuse, the ED may be the initial point of contact with the health
services system. It serves as a source of case identification and
referral to AOD detoxification programs. Certain illnesses treated in
emergency departments may mimic, mask, or resemble symptoms of
withdrawal from AODs. Urine and blood toxicology testing may assist ED
staff in making the correct diagnosis.
ED staff should refer patients who enter for detoxification to a more
appropriate treatment site as soon as they have been assessed and
stabilized. The ED of an acute care hospital is neither an appropriate
setting for detoxification, nor is it a cost-effective one. However,
because of the key role of the ED in the initial management and
identification of persons in need of detoxification, ED staff should
have both clinical expertise and familiarity with local AOD abuse
treatment resources.
Intensive Outpatient Programs. Intensive outpatient programs
offer a minimum of 9 hours a week of professionally directed evaluation
and treatment in a structured environment. Examples include day or
evening programs in which patients attend a full spectrum of treatment
programming but live at home or in special residences. Some programs
provide medical detoxification. Many programs have established linkages
through which they may refer patients to behavioral and psychosocial
treatment. One strength of these programs is the daily contact between
patients and staff. Another TIP in this series, Intensive Outpatient
Treatment for Alcohol and Other Drug Abuse, describes these programs in
detail.
Nonintensive Outpatient Programs. In nonintensive outpatient
programs, patients attend regularly scheduled sessions that usually
total no more than 9 hours of professionally directed evaluation and
treatment per week. These programs may provide detoxification services.
Treatment approaches and philosophies in staffing of outpatient programs
vary considerably. Some offer only assessments; in others, counseling
may continue for a year or longer. A majority of programs provide one
or two weekly patient visits and may deliver psychiatric or
psychological counseling and other services, such as resource referral
and management. Many combine counseling with 12-step recovery.
Methadone Maintenance (Maintenance Pharmacotherapy) Clinics.
These clinics may provide medically supervised withdrawal for persons
abusing heroin who do not want to enter a methadone maintenance program
but instead want to use methadone for withdrawal only, as well as for
people who want to withdraw from methadone maintenance. The clinics,
which must be licensed by the Food and Drug Administration, the Drug
Enforcement Administration, and State regulatory agencies, are the only
programs in which methadone maintenance may be conducted for opiate
addicts. They may be publicly funded and/or on a fee-for-service basis,
but the distinction between public and private clinics is not clearcut;
for example, many private clinics have contracts with the State or
county to provide detoxification services.
Social model programs that provide detoxification should have
reliable and routine access to medical services to manage medical and
psychiatric complications of their patients' withdrawal. The access may
be provided by a physician, nurse practitioner, or physician's
assistant. The panel suggested calling social model programs that
provide medical detoxification services under medical supervision a
"modified medical model." The purpose of the new name is to assist such
programs in obtaining reimbursement under State health care reform and
through managed care and third-party payers. The suggested name
"modified medical model" caused some controversy among the panelists and
field reviewers. Nonmedical panelists noted that the new name could
imply a "medical takeover" of social model programs. The panelists with
medical backgrounds and orientations pointed out that the current state
of the art of detoxification, particularly from alcohol and other
sedative-hypnotics and opiates, requires medical assessment and
prescription of medications. A closer alliance of the two models would
provide better patient care and make some program services reimbursable
by health care payers.
Advances in AOD abuse treatment over the past decade support this
type of program, which may be described as a social model program backed
up by all of the medical services needed to meet the physical needs of
the patient undergoing detoxification. The essential characteristics of
the ideal modified medical model are outlined under the following four
headlines.
The "modified medical model" detoxification program is headed by a
medical director who has knowledge of and skills in the treatment of
addiction and who holds ultimate responsibility for patient care. The
clinical responsibilities of the medical director include seeing
patients when necessary and remaining on call for consultations. The
director's primary administrative duties are supervising detoxification
staff and establishing clinical protocols.
Triage and ongoing patient evaluation are essential components of the
proposed "modified medical model." Staff regularly monitor each
patient's vital signs, and the decision to medicate or not to medicate
is made by a physician. Such a routine stands in sharp contrast to that
of traditional social model programs. Frequently, in these settings, no
one is available to monitor patients' vital signs. When crises occur,
patients must be transported to a local emergency department. This
practice is not cost-effective and does not ensure optimal patient
care.
A nurse practitioner or a physician's assistant manages day-to-day
program operations. If the staff of the modified medical detoxification
unit does not include a nurse practitioner or physician's assistant, the
medical director's time in the program is expanded.
The nurse's chief responsibilities are to monitor patients' vital
signs and to perform other nursing services. When an individual needs
medical attention, the nurses call on a member of the medical team, if
one is available to the unit, rather than referring the patient to an
emergency department. However, if a member of the medical team is not
available, the patient should be seen in an emergency department. A
registered nurse should remain on call, and nurse's aides (such as
rehabilitation technicians or detoxification aides) should be on duty at
all times. Appropriate support for the nurse's aides includes, at a
minimum, a nurse and a backup physician.
Ideally, all staff working in the program, including nurses, nurse
practitioners, nurse's aides, and physician's assistants, are trained in
detoxification and in the treatment of chemical dependency. Taking and
interpreting vital signs constitute a minimal standard of care, and some
staff members, such as nurse's aides, might be trained to interpret
signs relevant to AOD abuse issues, since such training is not provided
in many standard curricula. Nurse's aides undoubtedly would also
require additional training in AOD abuse issues in order to serve as
effective members of the care team in a detoxification unit. Program
administrators should establish minimum standards for licensure and
accreditation of modified medical programs and staff.
The best detoxification setting for a given patient may be defined as
the least restrictive, least expensive setting in which the goals of
detoxification can be met. The ability to meet this standard assumes
that treatment choices are always based primarily on a patient's
clinical needs. The least expensive care may not necessarily be the
best care for a given individual. Less expensive but clinically
inappropriate care will not be cost effective. It is often difficult to
know which patients will be able to reach their detoxification goals in
a relatively unrestricted setting, such as an outpatient AOD clinic, and
which patients will need closer medical supervision and more
comprehensive care. Decisionmakers should rely on clinical experience,
close collaboration on the part of the multidisciplinary team, and
respect for the patient's wishes to make the appropriate decision.
A comprehensive evaluation of the patient often indicates what
therapeutic goals might realistically be achieved during the time
allotted for the detoxification process. Alling (1992) suggested that such goals might include
"treating current medical problems discovered; helping the person
arrange for further drug-free rehabilitation following discharge; and
educating the person in the area of drug-related problems, such as
relapse prevention, health-related issues, and attention to family,
vocational, religious, and legal problems as may be required."
For those who seek additional guidance in this area, a number of
criteria sets have been developed to guide the process of matching
patients to treatment settings. The Patient Placement Criteria for
the Treatment of Psychoactive Substance Use Disorders (Hoffman, 1991), developed by the American Society
of Addiction Medicine (ASAM) in 1991, are used by many programs. The
ASAM criteria, which are intended for use as a clinical tool for
matching patients to appropriate levels of care, reflect a clinical
consensus of adult and adolescent treatment specialists and incorporate
the results of a field review.
According to the ASAM Patient Placement Criteria, the three goals for
management of detoxification are (1) avoidance of potential hazardous
consequences of discontinuation of the drug of dependence; (2)
facilitation of the patient's completion of detoxification and timely
entry into continued treatment; and (3) promotion of patient dignity and
easing of discomfort during the withdrawal process.
The ASAM criteria describe levels of treatment that are
differentiated by the following three characteristics:
Degree of
direct medical management provided
Degree of structure, safety, and security provided
Degree of treatment intensity provided.
The ASAM levels of care range from outpatient treatment to medically
managed intensive inpatient care. (The ASAM criteria do not provide for
detoxification in social model programs.)
The ASAM criteria offer a variety of options, on the premise that
each patient should be placed in a level of care that has the
appropriate resources (staff, facilities, and services) to assess and
treat the substance use disorder. While the criteria describe four
levels of care, variations in staffing and support services may give
some programs the capacity for more or less intense monitoring of
detoxification than other programs at the same level of care.
The levels of care addressed by the ASAM Patient Placement Criteria
are matched with the corresponding recommended detoxification settings
described in Exhibit 2-1. The TIP titled
The Role and Current Status of Patient Placement Criteria in the
Treatment of Substance Use Disorders (TIP 13;
Center for Substance Abuse Treatment, 1995) provides a framework to
help providers understand the issues surrounding patient placement
criteria and offers potential strategies that can be useful in
developing criteria. This TIP represents an initial effort to develop
criteria that are more consistent with the overall needs of the
treatment field.
It provides an analysis of several sets of public and private
criteria, including the ASAM criteria and those used by the States of
Minnesota, Massachusetts, and Iowa. The TIP provides recommendations
for filling in the gaps in existing criteria sets, so uniform criteria
can be developed that are acceptable to both treatment providers and
payers.
A managed care bibliography that includes information on patient
placement criteria is available from CSAT. This bibliography, titled
Annotated Bibliography: Substance Abuse Treatment Services and Health
Care Reform, can be obtained by contacting CSAT's Division of State and
Community Assistance at (301) 443-8391.
In recent years, some States have begun to develop standards of care
on the basis of models such as the ASAM Patient Placement Criteria. The
move toward the development of standards of care and their subsequent
application across a broad range of detoxification settings has
advantages and disadvantages.
Properly developed and executed, such standards have the potential to
ensure increased uniformity of treatment and improved appropriateness
and cost-effective allocation of resources. A basic consideration is
meeting these expectations while at the same time maintaining the focus
on the patient's clinical needs as the primary concern. Patient
placement criteria can provide a safety net that protects patients from
falling to the lowest level of care as a consequence of economic
considerations or a lack of treatment alternatives. A major risk in the
use of placement standards, however, is that they may be taken too
literally by those not directly involved in patient care. This could
result in a patient's receiving an inappropriate level of care that does
not meet his or her clinical needs.
Clinicians must exercise judgment in all cases. If a single approach
to care is widely adopted and strictly adhered to as the "correct"
approach, treatment innovation may be stifled. The chief value of any
criteria set is the added power that it gives providers to identify
specific patient needs by means of a consistent and detailed assessment
process and to choose a level of care that will specifically address
those needs.
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