J.  Is Detoxification Indicated?

 

OBJECTIVE

 

Identify patients who need detoxification from alcohol, sedative-hypnotics, or opioids.

 

ANNOTATION

 

Detoxification is an essential initial gateway in preparing many patients for additional treatment.  Pharmacological detoxification is warranted only for alcohol, sedative-hypnotics, and opioids.  For nicotine dependence, refer to the VHA/DoD Clinical Practice Guideline To Promote Tobacco Use Cessation in the Primary Care Setting.  Other drugs of abuse do not require pharmacological management for withdrawal.

 

Indications for detoxification from alcohol or sedative-hypnotics

1.       Medical monitoring of detoxification should be provided for dependence on central nervous system (CNS) depressants, due to the potential severity of untreated withdrawal in severely dependent persons.

2.        Mild withdrawal symptoms that are not accompanied by complicating comorbidities may not require pharmacological management and may respond sufficiently to generalized support, reassurance, and frequent monitoring (APA, 1995).

3.       Detoxification from sedative-hypnotics is indicated when there is physical dependence in the absence of clinical indications for ongoing treatment (e.g., anxiety or panic disorder) or when accompanied by “addict behavior” (e.g., prescriptions from multiple providers, patient escalating doses without provider consultation, or buying medications on the street).

 

Indications for opioid detoxification

  1. It is difficult to identify opioid addicted patients with good prognosis for successful opioid detoxification; however, the following are relative indications:

·      Briefer and less severe addiction history that does not meet regulatory criteria for opioid agonist treatment (see Annotation H)

·      Active commitment to an abstinence-oriented recovery program (e.g., monitored naltrexone, mutual help program involvement, and therapeutic community participation)

  1. Detoxification is contraindicated for individuals with two or more unsuccessful detoxification episodes within a 12-month period.  Such patients must be assessed by an opioid treatment program physician for alternatives to detoxification.

 

DISCUSSION

 

Detoxification from CNS depressants is not a complete treatment for substance dependence, although it can prepare patients for a comprehensive treatment strategy.  Simpson and Sells (1990) showed that patients in methadone maintenance, therapeutic community, or outpatient drug-free counseling had better outcomes than did patients who either did not follow-up after an intake assessment or received only detoxification without follow-up treatment.  Even among highly motivated patients who are clinically and psychosocially stable over several years (Magura & Rosenblum, in press), few achieve extended full remission after leaving treatment and many experience adverse outcomes such as death, incarceration, and HIV infection.

 

If a patient is physiologically dependent on sedative-hypnotics that are not being prescribed as part of an appropriate ongoing treatment regimen for underlying pathology (e.g., anxiety and seizure disorders), careful monitoring during detoxification is indicated.  While withdrawal symptoms are present or likely to emerge in a patient with moderate to severe physiologic dependence, detoxification in many cases can be safely accomplished without pharmacological management of withdrawal symptoms.

 

EVIDENCE TABLE

 

 

Recommendations

Sources of Evidence

QE

 

R

1

Mild withdrawal symptoms that are not accompanied by complicating comorbidities may respond sufficiently to generalized support, reassurance, and frequent monitoring.

APA, 1995

II-2

 

D

QE = Quality of Evidence; R = Recommendation (See Introduction)