L.  Does Patient Require Inpatient Detoxification?

 

OBJECTIVE

 

Identify the appropriate setting for safe and effective withdrawal management.

 

ANNOTATION

 

 1.   Ambulatory detoxification has the potential advantages of:

·   Facilitating continuity of care in the outpatient setting

·   Reducing disruption to the patient's life

·   Lowering costs in the outpatient setting

2.     While no definitive standard exists for setting up an ambulatory detoxification protocol, there should be systematic assessment and consistent monitoring.

3.     Inpatient detoxification allows closer monitoring of withdrawal symptoms and higher likelihood of completing the detoxification protocol.

·   There are fewer logistic medical and legal concerns (e.g., arranging for patient transportation, driving during the course of detoxification, and the ability to give informed consent).

·   While patients are more likely to complete the inpatient detoxification protocol, long-term outcomes do not indicate a difference between inpatient and outpatient detoxification programs.

4.     Consider the following indications for inpatient detoxification:

·   Current symptoms of moderate to severe alcohol withdrawal (e.g., CIWA-Ar score ³10)

·   History of DTs or withdrawal seizures

·   Inability to tolerate oral medication

·   Imminent risk of harm to self or others

·   Recurrent unsuccessful attempts at ambulatory detoxification

·   Reasonable likelihood that the patient will not complete ambulatory detoxification (e.g., due to homelessness)

·   Active psychosis or severe cognitive impairment

5.     Because medical complications and withdrawal severity are often the reasons for an inpatient detoxification admission, inpatient programs should provide adequate, on-site medical staffing in order to ensure patient safety during detoxification.

 

DISCUSSION

 

Compared to ambulatory detoxification settings, inpatient detoxifications can often be done more rapidly since access to alcohol and drugs is restricted.  Detoxification monitoring, performed while a patient is in a clinically managed residential setting (e.g., some VA Substance Abuse Residential Rehabilitation Treatment Programs [SARRTP]), is considered ambulatory.

 

EVIDENCE TABLE

 

	Recommendations	Sources of Evidence	QE		R
1	Indications for inpatient detoxification.	ASAM, 1996	III		A

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