Discussion Point: The standard for outpatient alcohol detox allows for the provider to assess the client in the office, prescribe the amount of medication for the next 24 hours and then send them home. This does not address the increased risk of falls, the effect of the medication on the ability for the client to remember to take the medication as prescribed. The patient is left to fend for themselves, for their meals and for additional medication for headache, insomnia, or diarrhea. Caregiving support services helps to keep the client safe, medications on a schedule and increase nutritional intake.

       

American Family Physician


In 1992, approximately 13.8 million Americans (7.4 percent of the U.S. adult population) met the criteria for alcohol abuse or dependence as specified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR). In 2000, 226,000 patients were discharged from short-stay hospitals (excluding Veteran’s Affairs and other federal hospitals) with one of the following diagnoses: alcohol withdrawal (Table 1), alcohol withdrawal delirium, or alcohol withdrawal hallucinosis. It is estimated that only 10 to 20 percent of patients undergoing alcohol withdrawal are treated as inpatients,4 so it is possible that as many as 2 million Americans may experience symptoms of alcohol withdrawal conditions each year.

Goals of Detoxification

The American Society of Addiction Medicine lists three immediate goals for detoxification of alcohol and other substances: (1) “to provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug-free”; (2) “to provide a withdrawal that is humane and thus protects the patient’s dignity”; and (3) “to prepare the patient for ongoing treatment of his or her dependence on alcohol or other drugs.”

Discussion Point: START@home caregiving support services address the first two goals by having caregiver support present during an outpatient/ambulatory alcohol detoxification.

Choice of Treatment Setting

In most patients with mild to moderate withdrawal symptoms, outpatient detoxification is safe and effective, and costs less than inpatient treatment. However, certain patients should be considered for inpatient treatment regardless of the severity of their symptoms. Relative indications for inpatient alcohol detoxification are as follows: history of severe withdrawal symptoms, history of withdrawal seizures or delirium tremens, multiple previous detoxifications, concomitant psychiatric or medical illness, recent high levels of alcohol consumption, pregnancy, and lack of a reliable support network.

Discussion Point: START@home admission criteria cover exclusionary criteria as well that follow these guidelines. Safety for the client and for the caregivers is a priority.

If outpatient treatment is chosen, the patient should be assessed daily. The patient and support person(s) should be instructed about how to take the withdrawal medication, the side effects of the medication, the expected withdrawal symptoms, and what to do if symptoms worsen. Small quantities of the withdrawal medication should be prescribed at each visit; thiamine and a multivitamin also should be prescribed. Because close monitoring is not available in ambulatory treatment, a fixed-schedule regimen should be used.

Discussion Point: Clients are monitored following the CIWA-Ar protocol. All Medications are administered per written provider orders based on monitoring data gathered.

In most patients with mild to moderate withdrawal symptoms, outpatient detoxification is safe and effective, and costs less than inpatient detoxification.

Benzodiazepines have been shown to be safe and effective, particularly for preventing or treating seizures and delirium, and are the preferred agents for treating the symptoms of alcohol withdrawal syndrome.

Bayard M.D., M., Mcintyre, M.D., J., Hill, M.D., K.R., & Woodside, Jr., M.D., J. (2004, March). Alcohol withdrawal syndrome. American Family Physician, 69:1443-50

http://www.aafp.org/afp/2004/0315/p1443.pdf

       

American Society of Addiction Medicine


Definition of Medically Monitored: Services provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialist and other health and technical personnel under the direction of a licensed physician. Medical monitoring is provided through appropriate mix of direct patient contact, review of records, tram meetings, 24 hour coverage by a physician and a quality assurance program.

Discussion Point: No Worries has been providing medication administration and monitoring for our clients for 15 years. We do caregiving support with every client; we work under physician’s orders. START@home provides that same caregiving support during the alcohol detoxification process.

Patient Placement Criteria for Detoxification (PPC-2R)
      • Level I.D: Ambulatory Detoxification without Extended On-site Monitoring (e.g., physician office practice/home health care)
      • Level II-D: Ambulatory Detoxification with Extended On-site Monitoring (e.g., detoxification on partial hospitalization program)
      • Level III-D: Residential/Inpatient Detoxification
      • Level III.2D: Clinically Managed Residential Detoxification (e.g., social detox)
      • Level III.7D: Medically Monitored Inpatient Detoxification
      • Level IV-D: Medically Managed Inpatient Detoxification

Discussion Point: START@home is not a facility but a caregiving service, doing what we have always done for clients at No Worries.

Levels of Care
      • Level 0.5- Early Intervention
      • Level I- Outpatient
      • Level II- Intensive Outpatient/Partial Hospitalization
      • Level III- Residential/Inpatient Treatment
      • Level IV- Medically Managed Intensive Inpatient Treatment

Discussion Point: Outpatient detox, also known as ambulatory detox can be done in the home or hotel or even on the street. Our Services help to make the physician-ordered detox safer.

www.valueoptions.com/kansas/.../ASAM_training_110107.ppt

Lever 1 – OUTPATIENT SERVICES
      • 1D – Ambulatory Detox without extended On-site monitoring
      • Outpatient Treatment – traditional Level 1
Level 2 – INTENSIVE OUTPATIENT / PARTIAL HOSPITILIZATION SERVICES
      • IID – Ambulatory Detox with extensive On-site monitoring
      • II.1 – Intensive Outpatient
      • II.5 – Partial Hospitalization

http://www.apofla.com/dl/ASAM/Levels_of_Care_Definitions_1-9-05.pdf

       

American Journal of Drug and Alcohol Abuse


With careful screening, most alcohol treatment programs find that less than 10% of patients with alcohol withdrawal symptoms will need admission to an inpatient unit.

Ambulatory medical detoxification for alcohol forced the treatment field to refine its ability to match patients with appropriate levels of care.

It is important to clarify that ambulatory detoxification procedures are intended to supplement inpatient detoxification and not to replace inpatient facilities.

There are several important advantages of ambulatory alcohol medical detoxification for alcohol. Chief among these advantages are that patients can continue to function in their home environment and remain at work. It has been adequately demonstrated that ambulatory detoxification is safe and effective for mild to moderate detoxification. Total withdrawal time is less than inpatient detoxification, and ambulatory detoxification has been shown to be as effective as inpatient programs in assuring continuity of care. Ambulatory detoxification can be done with less resources than inpatient withdrawal or social detoxification, and is considerably less costly. Real life dilemmas can be dealt with as patients are withdrawing; this could potentially minimize denial and provide a better setting to devise strategies to resist relapse and maintain abstinence. Lastly, patients are active participants in treatment during ambulatory detoxification, which provides the patient a sense of responsibility and control.

Discussion Point: Another goal of the in-home and in-hotel alcohol detox setting is the reduction in cost to the client.

Significant advances have been made in the refinement and implementation of outpatient medical detoxification for alcohol. This has included the description of admission criteria; demonstration of safety, and proven effectiveness. More importantly, the alcohol field is identifying the need for alternative levels of care and the necessity of matching patients to appropriate levels of care and specific types of interventions. This has recently been recognized by the American Society of Addiction Medicine (ASAM) in the development of their guidelines for the selection of appropriate levels of care.

Discussion Point: We have admission criteria that included exclusionary criteria.

Abbott, Patrick J., Leigh Knox, and Diana Quinn. "Ambulatory medical detoxification for alcohol." American Journal of Drug and Alcohol Abuse 21.4 (1995): 549+. Health Reference Center Academic. Web. Document URL http://0-go.galegroup.com.catalog.multcolib.org/ps/i.do?id=GALE%7CA17495786&v=2.1&u=multnomah&it=r&p=HRCA&sw=w

       

Alcohol Health & Research World


Advantages of Outpatient Detoxification

For patients with mild-to-moderate alcohol withdrawal syndrome, characterized by symptoms such as hand tremor, perspiration, heart palpitation, restlessness, loss of appetite, nausea, and vomiting, outpatient detoxification is as safe and effective as inpatient detoxification but is much less expensive and less time consuming (Hayashida et al. 1989). In addition, patients who enroll in long-term outpatient rehabilitation treatment following detoxification in an outpatient setting may benefit by attending the same treatment facility for both phases of treatment. Most outpatients experience greater social support than inpatients, with the exception of outpatients in especially adverse family circumstances or job situations. Outpatients can continue to function relatively normally and maintain employment as well as family and social relationships. Compared with inpatients, those patients in outpatient treatment retain greater freedom, continue to work and maintain day-to-day activities with fewer disruptions, and incur fewer treatment costs.

Disadvantages of Outpatient Detoxification

Among the drawbacks associated with outpatient detoxification is the increased risk of relapse resulting from the patient’s easy access to alcoholic beverages. In addition, outpatients can more easily choose not to keep their detoxification appointments and, consequently, fail to complete detoxification. In one study of 164 patients randomly assigned to either inpatient or outpatient detoxification, significantly more inpatients than outpatients completed detoxification (Hayashida et al. 1989). The higher completion rate among inpatients should not be interpreted as an indicator of long-term sobriety, however. Inpatients who successfully completed detoxification might have either dropped out of treatment or returned to drinking had they been treated in the outpatient setting. Thus, although inpatients may be more likely to complete detoxification, they may be arbitrarily postponing the chance to resume drinking after discharge. Outpatient detoxification is not appropriate for all patients. Most alcohol treatment programs find that fewer than 10 percent of patients with alcohol withdrawal symptoms will need admission to an inpatient unit (Abbott et al. 1995). Outpatient detoxification is not safe for alcoholics at risk for potentially life-threatening complications of withdrawal, such as delirium tremens, or those with associated medical conditions such as pancreatitis, gastrointestinal bleeding, or cirrhosis. In addition, outpatient detoxification is not appropriate for suicidal or homicidal patients, those with severe or medically complicated alcohol withdrawal, patients in adverse or disruptive family or job situations, or patients who would not be able to travel daily to the treatment facility.

Discussion Point: Another factor to consider is that with only one exception where the client refused to quit drinking, all of our detox clients completed their alcohol detoxification with our caregiving support model while we offered these services exclusively to physicians at Beyond Addictions. During our three years providing this service, we had one client that had to go to the emergency room; it was for a reaction to Phenergan. Once stabilized, the client returned home and finished the detox.

Hayashida, M.D., M. (1998) An overview of outpatient and inpatient detoxification. Alcohol Health & Research World, (22), 1. Pp. 44-46

http://pubs.niaaa.nih.gov/publications/arh22-1/44-46.pdf

       

Journal of Family Practice


Outpatient Treatment

Most alcohol treatment programs find that <10% of patients need admission to an inpatient unit for treatment of withdrawal symptoms. For patients with mild-to-moderate alcohol withdrawal symptoms (CIWA-Ar <15), and no serious psychiatric or medical comorbidities, outpatient detoxification has been shown to be as safe and effective as inpatient detoxification. Additionally, most patients in an outpatient setting experience greater social support, and maintain the freedom to continue working or maintaining day-to-day activities with fewer disruptions, and incur fewer treatment costs.

Pharmacotherapy: Benzodiazepines

Benzodiazepines are the mainstay of treatment in alcohol withdrawal (number needed to treat [NNT]=17; data from large meta-analysis of 6 prospective, placebo-controlled trials). Like alcohol, these agents magnify GABA’s effect on the brain. Benzodiazepines are cross-tolerant with alcohol; during withdrawal from 1 agent, the other may serve as a substitute. Benzodiazepines also reduce the incidence of DTs and seizures (Table 1).

Treatment Regimens

The acceptable medication regimens for treating alcohol withdrawal are the gradually tapering dose approach, the fixed-schedule approach, and the symptom-triggered approach. The first 2 regimens are appropriate for the pharmacological treatment of outpatient alcohol detoxification.

Gradually tapering regimen. With the gradual-dosing plan, patients receive medication according to a predetermined dosing schedule for several days as the medication is gradually discontinued (Table 2).

Fixed-schedule regimen. In the fixed-schedule dosing regimen, the patient receives a fixed dose of medication every 6 hours for 2 to 3 days regardless of severity of symptoms.

Symptom-triggered regimen. For the symptom-triggered approach, the patient’s CIWA-Ar score is determined hourly or bihourly and the medication is administered only when the score is elevated. Typically, benzodiazepines are used in a symptom-triggered regimen, although either benzodiazepines or anticonvulsants may be used in a fixed-schedule plan.

The main advantage to the symptom-triggered approach is that much less medication is used to achieve the same withdrawal state. The symptom-triggered approach has also shown a possible decrease in DTs and may lead to less over-sedation.

We favor a symptom-based approach whenever adequate periodic assessment of CIWA-Ar can be performed, such as in an inpatient setting. For those patients who require pharmacological treatment during outpatient detoxification (CIWA-Ar score 8–15), we prefer the gradually tapering or fixed dosing plan, to provide a margin of safety, simplify the dosing schedule, and maximize compliance.

Asplund, MD, C. A., Aaronson, DO, J. W., Aaronson, DO, H. E. (July 2004). 3 Regimens for alcohol withdrawal and detoxification. Journal of Family Practice, (53), 7. Retrieved from http://www.jfponline.com/Pages.asp?AID=1730.

Discussion Point: There is a general myth that alcohol detox is dangerous and unpredictable. This is true when a person tries to detox on their own with no medical support or is forced into withdrawal due to circumstances. When a person goes through a monitored medical alcohol detox with benzodiazepines, the detox follows a predictable pathway to conclusion.