benzodiazepines to experience significant
withdrawal symptoms lasting between 10 and 14
days,^79 and symptoms can persist for four to six
months.^80 Therefore, it is recommended that
benzodiazepine detoxification extend over a
period of weeks or months--tapering the patient
off the drugs over time. Another option for
detoxification from benzodiazepines is to
prescribe a different drug from the class, one
with a longer half-life, such as
chlorodiazepoxide or clonazepam.^81
Detoxification Venues. Detoxification can take
place in a variety of settings including the
patient’s home (monitored and managed by
trained clinicians), physicians’ offices, non-
hospital addiction or mental health treatment
facilities, urgent care centers and emergency
departments, intensive outpatient and partial
hospitalization programs and acute care inpatient
settings.* 82
For planned, monitored or medically-assisted
detoxification, health-care providers, considering
the specific needs of the patient, typically
determine the venue for detoxification. Patients
should be placed in the least restrictive setting
possible.^83 Beginning in the 1970s, there was a
movement toward medical ambulatory
detoxification, primarily for alcohol, that
maintained high safety and efficacy profiles while
being more cost effective than inpatient
detoxification. Ambulatory care was intended to
supplement rather than replace inpatient medical
detoxification with the understanding that there
were some people for whom inpatient care still
was necessary. The ability to continue to meet life
responsibilities as well as relatively lower costs
are advantages of outpatient detoxification.^84
The primary substance involved in the addiction,
the severity of the symptoms and particular
patient characteristics (e.g., age, co-occurring
substance use and other health conditions) all
play important roles in determining the
appropriate venue for detoxification. For
- Such as acute care general hospitals, acute care
addiction treatment units within those hospitals, acute
care psychiatric hospitals and other specialty
hospitals licensed to provide addiction treatment.
example, patients with a history of severe
withdrawals or multiple withdrawals should not
be placed in nonmedical settings for
detoxification.^85 For patients deemed a danger
to themselves or others, medically-managed
intensive inpatient treatment or emergency
hospitalization in a psychiatric facility is
recommended.^86 For patients with mild or
moderate withdrawal symptoms, outpatient
detoxification can be just as effective as
inpatient, provided the patients have a positive
and helpful social support network.^87Acute Care .........................................................................................................................
Effective, clinical treatments for addiction
include a significant and growing range of
pharmaceutical and/or psychosocial therapies
delivered by qualified health professionals. Due
to the complex nature of addiction and its
physiological, psychological and environmental
risk factors, a multi-pronged approach to its
treatment that includes a combination of
pharmaceutical and psychosocial therapies
typically yields the best results.^88 Because of the
extent to which addiction co-occurs with a broad
range of other health problems, effective
medically-managed acute treatment protocols
also should address both co-occurring disorders
and patients’ nutrition and exercise
requirements.^89Guidelines set forth by the American Society of
Addiction Medicine’s (ASAM) patient
placement criteria increasingly are being used by
treatment programs, government programs,
managed care companies and other
organizations to appropriately match patient
needs to specific treatment services and to
determine the appropriate level of care.^90Pharmaceutical Therapies ............................................................................................
As with most medical conditions,
pharmaceutical therapies can be an important
component of addiction treatment,^91 particularly
for patients who are highly motivated to adhere
to the medication regimen.† 92 (Table 5.1)† For less motivated patients, supervised
administration of the medication may be necessary.