Our Experience with Implementing an Outpatient Detoxification Program

Philip J. Gyura, MS, FNP-BC
Casey Clark, MS, FNP-BC

Among Americans aged 12 or older, approximately 24.6 million, or 9.4%, were current illicit drug users in 2013, and 21.6 million (8.2%) were classified with substance dependence or abuse, according to US government estimates.1 Moreover, of the 22.7 million persons (8.6%) in the United States aged 12 or older who needed treatment for a drug or alcohol problem in 2013, only 2.5 million persons received specialty facility treatment. This means that 20.2 million Americans who needed treatment that year did not receive it.1

Addiction is a disease of the brain that typically presents as a chronic illness, requiring multiple episodes of treatment to achieve abstinence.1 The first step in most treatment programs is medically assisted detoxification, after which patients typically enter a formal treatment program.1 Detoxification refers to the safe, controlled cessation of a substance of dependence.2 Detoxification is not the end of use. Instead, it is seen as a transition from dependence to abstinence. True recovery of substance misuse and dependence is a much more involved process, which is why detoxification is recommended in conjunction with psychosocial therapy.2 The choice of outpatient vs inpatient detoxification program is based on the provider’s clinical judgment and the patient’s preferences, degree of dependence, lifestyle, and living situation.2

Because of the high rate of substance abuse in the US, the New York State Office of Alcoholism and Substance Abuse Services (OASAS) developed guidelines for an outpatient detoxification program3 in qualifying outpatient substance abuse treatment programs and methadone maintenance treatment programs in clinics in New York.3 The OASAS outpatient detoxification program provides guidelines for the use of medications that are reimbursed by Medicare and Medicaid. The health care provider enforces the program with the patient by having daily visits, checking vital signs, and monitoring medications to ensure patient adherence to the guidelines.

 

Background

The program was monitored from May to August 2013 in 2 methadone clinics with 3 providers in New York City. Casey Clark and I were recruited as students doing clinical in the institution and were asked to help start the program. We were excited about the prospect of offering a needed service in a high-need area. Our role in the program was to help streamline the paper charting process and to work with the providers on making a more seamless program to encourage the providers use of it. We did not have any patient contact or review any charts, so the program did not require institutional review-board approval. The program was free for patients, but they had to be enrolled in a methadone program to have access.

 

Program Enrollment

Health care providers and nurse practitioner (NP) students at both clinics recruited patients into the program during patients’ annual medical visits; the program had not been publicly advertised. Enrollment was based on patients’ previous and current substance use, withdrawal scores from standard tools (such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised [CIWA-Ar] and the Clinical Opiate Withdrawal Scale [COWS]), and medical evaluation performed by health care providers prior to any treatment. Patients who were interested in abstinence were screened using a form created by the NP students; if patients were eligible, they were started on medication that day.

To be eligible for the outpatient program, participants had to be patients of the clinic, have a recent complete physical examination, and have a documented substance abuse history with supporting laboratory test results, such as a positive drug test result. Patients at high risk for developing complications while in the program, including those with previous detoxification attempts and comorbid conditions requiring monitoring, were excluded. Patients with a history of seizures also were excluded, since they should be monitored in an inpatient setting; they and others who were not eligible for the outpatient program were referred to an inpatient program at a nearby hospital.

 

Documenting and Treating Patients

The NP students facilitated communication and documentation during the development of the program and collected feedback about the forms and how the program could be improved. They assessed patient needs such as transportation, access to medication, and waiting area conditions, and they implemented standard documents that the physicians, nurses, and medical assistants could use to track patients’ progress.

The NP students created 3 forms using tools in the New York State OASAS.3 The first form was an admission form for the outpatient detoxification program on which the health care provider could document the initial assessment, indicate the medication to be used, and indicate which protocol will be followed. This form could be expanded to include the findings of a complete physical examination, laboratory test results, a psychiatric history, and a comprehensive drug use and medical history.

The second form they created used the CIWA-Ar scale for addressing alcohol withdrawal. The form was designed to be completed every day to record the 7-day detoxification, to help keep information in one place, to assist with consistency, and to monitor trends in the withdrawal stages. Health care providers also could use this form to document daily assessments of relapse, proper adherence to home medication, and doses of as-needed medications. Thiamine, 100 mg, was added to the form as an as-needed medication, because the health care providers wanted all alcohol withdrawal patients to receive it.

Our plan originally called for the health care providers to use symptom-based dosing, a method of treating patients every few hours based on first-hand observations. However, due to lack of physical space at the clinics and patients’ lack of interest in staying at the clinics, this could not always be accommodated. Instead, the health care providers used a scheduled dosing plan, a method of treating patients with a set amount of medication based on 1 observation per day. According to published research on alcohol withdrawal,4 there is no difference between using the symptom-based method or scheduled dosing method.

Using the scheduled dosing method, the health care providers assessed patients participating in the alcohol detoxification program at the start and would initiate medications with chlordiazepoxide, 25 to 50 mg every 6 to 8 hours, with doses given for CIWA-Ar scores above 12. Patients would be given their first dose after their assessment each morning and then would be monitored for 30 to 60 minutes. Medication was administered every 6 to 8 hours based on withdrawal schedule. At night, patients would be sent home with 1 or 2 doses to get through the night and with instructions for what to do in case of an emergency.

The COWS protocol was used in the opioid detoxification program and in benzodiazepine (BZD) withdrawl.3 Opioid detoxification can take weeks, and space was not available on the single-use CIWA-Ar form to accommodate that amount of time. The COWS form includes a space for assessing first-time medication administration. Opioid detoxification was accomplished using norbuprenorphine-naloxone (Suboxone, Indivior Inc) tapered over 7 to 10 days. The protocol called for assessment of the patient for withdrawal symptoms and adverse reactions 30 minutes after and 2 hours after norbuprenorphine-naloxone had been administered.

Patients in the BZD detoxification program were treated with phenobarbital on a tapering scale. This allowed the providers to monitor barbiturate levels in patients’ urine, and if any test results were positive for BZDs, the providers knew that the patient had relapsed. Phenobarbital also has less street value than BZDs, reducing the risk of patients selling their medications. Another treatment option with BZDs is to use the patient’s drug of abuse and gradually taper the dosage over many weeks. Patients generally prefer this method, but monitoring continuity is harder. Providers also can convert the dosage to a longer-acting diazepam and titrate it.2

Patients in the BZD withdrawal program also were assessed at 30 minutes after and 2 hours after medication administration.

Patients in both the BZD detoxification and the opioid detoxification programs were expected to return daily for medication administration and monitoring.

Each provider assessed BZD withdrawal subjectively based on the patient’s presenting symptoms; no specific scale was used to assess symptoms, but the COWS form could be used to help quantify their assessment. Withdrawal from BZDs should be gradual to get the patient down to the lowest possible dose of the either phenobarbital or the chosen BZD.2 Therefore, providers must be willing to work with patients over a prolonged period and be flexible in medication dosing, because some patients may require an increased dose if their symptoms become worse or patients might have to be on a dosage longer than the scheduled set.

To determine adherence among patients in the alcohol detoxification program, nurses assessed each patient by Breathalyzer test to determine whether the patient had consumed alcohol within the previous few hours. Patients in the BZD detoxification program were monitored using urine toxicology screens periodically as chosen by the health care providers. No patients were enrolled in the opioid withdrawal program during our time with the program. In the population studied, methadone was the preferred maintenance option.

 

Outcomes

Having universal documentation, tools, and guidelines allowed for appropriate data analysis of outcomes, improved communication between team members at both sites, and improved patient adherence to practice guidelines.

Evaluation of the program was based on interviews with the involved health care providers, since the project was not institutional review-board–approved and was not endorsed for chart review. After 4 months of our participation with the program, fewer than 50 patients had participated, and the new service suffered tremendously with transiency and relapse among its participants, particularly within the alcohol detoxification program.

The BZD detoxification program had the greatest retention rate, with more than half of participants returning to the clinic for administration and titration of their medication. One medical provider felt this likely related to the fact that patients were prescribed their own medication of addiction rather than phenobarbital.

Relapse remained high in both alcohol and BZD patient populations, with many participants dropping out of the program due to usage, or subsequently returning to the program after initially completing it. Only 2 patients completed the program by the end of our 4 months with the program. The opioid detoxification program experienced the least usage by providers and patients. The providers felt that the patients were not good candidates for withdrawal, and the patients did not want to give up the methadone treatment.  

 

Suggestions for Improving the Program

To help maximize patient success in this program, a number of suggested measures can be taken.

Some kind of interactive program could be set up to keep patients engaged during the day to help prepare them for long-term abstinence. This program could include a 12-step meeting led by volunteers, or a facilitated group led by a professional. The time spent in the clinic could be used to educate patients and develop tools needed to achieve sobriety. Having patients stay in the clinic will also improve patient safety; most patients do not have the stable, safe home environments needed for withdrawal.5 To help with adherence, health care providers should communicate the importance of staying at the clinic before patients agree to start the program, so that patients can plan accordingly.

The outpatient detoxification program would do well in an outpatient treatment setting, in which patients receive treatment during the day using groups and therapy, go home at night, and return daily over a specified period. Such a program would allow for proper monitoring. Adherence can be better monitored if patients attend a group session or 2 during the detoxification period. If this is not feasible, a sitting area with a TV and access to food and a lavatory would be helpful. Depending on the facility, patients might be allowed to leave for a short time in a designated area if they need to smoke or just get outside. Another issue is ensuring that patients have transportation to and from the facility. This was not an issue for the patients my group cared for, because they used public transportation or lived close to the clinic. In settings that do not have access to public transportation, patients would need to arrange transportation every day to and from the clinic.

Using phenobarbital or switching to a long-acting diazepam,2 instead of prescribing the patient’s drug of choice for the BZD detoxification program, could help monitoring and lessen the likelihood of the patient selling the prescribed BZDs on the street. This could hurt adherence, however, because patients reported not liking the way phenobarbital makes them feel compared with a BZD. This decision is not easy to make and requires weighing the pros and cons for each population.

Patients with opioid addiction who do not want to be on a maintenance program need other options. The use of maintenance drugs such as methadone and norbuprenorphine-naloxone in addition to psychotherapy in early opioid addiction recovery has been shown to have higher success rates.6 Long-term use of norbuprenorphine-naloxone shows signs of creating flat affects in patients,7 and, as their lives change, patients may not want to remain on maintenance drugs. Patients should know they have options outside of maintenance, and those options need to be made available in order for patients to succeed in their sobriety.

Philip J. Gyura, MS, FNP-BC, AAHIVS, is a student in the Doctor of Nursing Practice program at the Columbia University School of Nursing and a family nurse practitioner at Harlem United in New York, New York.

Casey M. Clark, MS, FNP-BC, is … at Columbia University School of Nursing in New York, New York.

References:

  1. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality; September 2014. NSDUH Series H-48. HHS Publication (SMA) 14-4863.
  2. Diaper AM, Law FD, Melichar JK. Pharmacological strategies for detoxification. Br J Clin Pharmacol. 2014;77(2):302-314.
  3. New York State Office of Alcoholism and Substance Abuse Services. Ancillary withdrawal management for 822 programs. https://www.oasas.ny.gov/AdMed/recommend/documents/822AncillaryWithdrawalPrograms.pdf.  Accessed April 6, 2016.
  4. Elholm B, Larsen K, Hornnes N, Zierau F, Becker U. Alcohol withdrawal syndrome: symptom-triggered versus fixed-schedule treatment in an outpatient setting. Alcohol Alcohol. 2011;46(3):318-323.
  5. Muncie HL Jr, Yasinian Y, Oge' L. Outpatient management of alcohol withdrawal syndrome. Am Fam Physician. 2013;88(9):589-595.
  6. Bart G. Maintenance medication for opiate addiction: the foundation of recovery. J Addict Dis. 2012;31(3):207-225.
  7. Hill E, Han D, Dumouchel P, et al. Long term SuboxoneTM emotional reactivity as measured by automatic detection in speech. PLoS One. 2013;8(7):e69043.