Outpatient Detoxification Strategies at ASAM

(This is the first of a two-part series on presentations given at the recent American Society of Addiction Medicine [ASAM] meeting in San Diego. A report on outpatient detoxification strategies for stimulants and opiates will appear in a subsequent issue--Ed.)

Detoxification from alcohol and drugs can be safely accomplished in outpatient settings, according to symposium reports presented at ASAM's 28th Annual Medical-Scientific Conference.

Careful selection of appropriate patients and frequent monitoring were key elements of successful detoxification strategies described in the symposium organized and chaired by Norman Miller, M.D., division of addiction treatment programs, University of Illinois at Chicago.

Alan Wartenberg, M.D., Addiction Recovery Program, Faulkner Hospital, Boston, said the success of outpatients withdrawing from alcohol without serious medical complications and continuing in recovery programs was comparable to success rates of inpatients. He attributed the outpatient successes to the careful selection of patients, the triage process and good nursing and medical assessments.

"The regimens are the least important thing you do. The medication you give is really not the significant issue," he said.

Selection Criteria

To increase the likelihood of successful, safe detoxification, the Faulkner Hospital program applies several criteria to determine patients' suitability for the outpatient program. Patients are younger than 60 years of age "physiologically," Wartenberg said, since younger alcoholics in markedly deteriorated condition may not be eligible while some older patients in relatively good health have been accepted. A history of recent or recurrent seizures, or of seizures accompanying past detoxification attempts, will preclude patients beginning detoxification as outpatients. Patients are also ineligible for detoxification as outpatients if they are so impaired or have sufficiently severe concurrent mental disorders that they are unable to follow treatment instructions. In addition, patients taking drugs which could complicate the alcohol detoxification process are not detoxified as outpatients.

Outpatients beginning alcohol detoxification must be in good general health, explained Wartenberg, because the detoxification process can be like a stress test.

"The levels of catecholamines that are seen in significant alcohol withdrawal are second only to pheochromocytoma. So it is basically like putting someone on a treadmill."

Outpatients of the Faulkner Hospital program are required to have adequate psychosocial support, in addition to that extended by the program. They must have and maintain close contact to a responsible party who will facilitate their following treatment directions; they must have access to transportation so that they do not drive; and they must keep their clinic appointments, which are scheduled daily or every other day. Wartenberg acknowledged that the majority of the patients participating at Faulkner have health insurance and commensurate resources.

Outpatients must be in a "good recovery environment" to succeed, Wartenberg said. "You can't be coming in from a cardboard box over a heating grate. You have to have or create sober houses, acute residential settings-something where the patient can stay and be transported. People coming to outpatient treatment from crack houses, from drinking homes, from destructive environments are not too likely, in my opinion, to recover."

The potential for a severe detoxification based on a history of high alcohol consumption, a high blood alcohol level or objectively graded severe withdrawal symptoms on presentation will also preclude initial detoxification in the outpatient setting. Specifically, the Faulkner program excludes patients from outpatient detoxification who report a daily alcohol consumption exceeding 300 mg, approximately a pint; those presenting to the program with an alcohol blood level exceeding 150 mg %; those whose symptoms are graded over 10 to 12 on the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) or who require an excess of 200 mg chlordiazepoxide (Librium) equivalent daily to control withdrawal symptoms.

In interpreting the CIWA-Ar scores, Wartenberg explained that the direction of the score changes should be considered, as well as the point in the withdrawal process and the alcohol level present at the time the scores are obtained. A patient with a CIWA-Ar score over 8 with a blood alcohol level above 100 mg %, for example, should be considered at very high risk for a severe detoxification, and not eligible to begin detoxification as an outpatient.

In general, Wartenberg will not provide benzodiazepines for symptoms graded below 5 on the CIWA-Ar, but will observe and provide other measures for comfort. Patients with symptoms rated from 5 to 9 are likely to receive the equivalent of 25 mg chlordiazepoxide four times daily for two days followed by 10 mg four times daily for two days. Symptoms scored between 10 to 12 are often treated with the equivalent of 150 mg daily of chlordiazepoxide for two days and then 75 mg daily for two days.

In each case where chlordiazepoxide or another benzodiazepine is administered, two additional doses are provided in "PRN packets," for use after leaving the clinic. Wartenberg strongly recommended that patients receive these PRN doses rather than prescriptions that require subsequent filling. His patients are instructed to notify the clinic when a PRN dose is taken, and to immediately return to the clinic if the second PRN dose is required.

The rate of these selected outpatients at Faulkner Hospital successfully withdrawing from alcohol and continuing on in recovery programs was comparable at three-month follow-up to the rate of success from the inpatient program. Although Wartenberg acknowledged that patients were lost to follow-up in both programs, of those able to be contacted at three months, 67% (61 of 90) outpatients and 64% (219 of 342) inpatients in 1995 remained sober and in recovery programs; and 60% of outpatients and 74% of inpatients in 1996 were similarly successful.

Wartenberg concluded that the outpatient and inpatient programs were comparably effective, with the outpatient program involving less cost.

"It did not seem to make a difference in alcohol-detoxing patients," he said. "It looked like with proper triage, proper selection, proper treatment, at least the short-term follow-up rate was equal for inpatient versus outpatient alcohol detoxification."

Although the experiences with opiate and benzodiazepine detoxification outpatient programs would be shared by other presenters, Wartenberg offered a cautionary note from his results at Faulkner Hospital. "Our opiate results were similar [to alcohol] in the same way: we had equal results [approximately 15% retention in recovery programs] with inpatient and outpatient opiate detoxification. The difference is, while I think our results with alcohol were equally good, the results with opiates were equally lousy."

Wartenberg also related his poor experience with treating benzodiazepine abusers as outpatients. He noted, however, that his population of "heavy abusers" differed from the patients in successful programs who were often selected for using benzodiazepines excessively, but for therapeutic indications. With heavy abuse, patients frequently obtained their supply of prescription benzodiazepines from several physicians, Wartenberg said.

"If you have a group who have 26 different doctors giving them their meds, you [detoxification clinic] are just the 27th," he added.

Breaking from Benzodiazepines

Miller recounted several novel outpatient benzodiazepine detoxification programs from the literature, including one using carbamazepine (Tegretol) as an adjunct, and another conducted with patients maintained on methadone. He commented, "Many of the studies on detoxifying people from benzodiazepines have been done on an outpatient basis. I think it is a standard of care."

Miller noted that the slow benzodiazepine tapering that is customarily necessary without adjunctive anticonvulsant medication typically becomes most difficult for patients in the last half, and particularly in the last quarter when patients are close to discontinuing the benzodiazepines.

"More of the withdrawal symptoms are evident in the last of the taper," he said.

Miller emphasized the importance of close, daily contact during the entire detoxification tapering period, although acknowledged the problem in professionals being reimbursed for such frequent consultation. Miller was in agreement with Wartenberg on the value of providing one to two days of benzodiazepine doses rather than a prescription to be filled or, worse, a prescription or quantity sufficient for an extended period.

In considering the requirement to gradually taper benzodiazepines, Miller commented, "What the studies do show is virtually anyone who has been on them for more than a few weeks has some kind of withdrawal symptoms. In general, the longer one is on a benzodiazepine and the higher the dose of the benzodiazepine, the more likely, and the more severe the withdrawal will be."

Tapering schedules should be individualized for patients, Miller said, with adjustments made as patients provide frequent feedback on their progress and level of discomfort. They can be expected to experience excitability, agitation and insomnia, Miller explained. He suggested that a typical tapering regimen begin with 50% of the patient's current daily dose, and decrease by 10% daily. The regimen would be completed for low to moderate doses of short-acting agents in seven to 10 days, and 10 to 14 days for long-acting agents. These periods are often longer, Miller noted, with high-dose regimens and when there is psychiatric or medical comorbidity.

The choice of whether to taper with the benzodiazepine being used by the patient or with a substitute is often based upon the clinician's preference, and Miller indicated his preference for substituting a long-acting benzodiazepine such as diazepam (Valium) for short-acting agents.

"I prefer this method because the severity of withdrawal from a short-acting benzodiazepine is greater than the withdrawal from a long-acting benzodiazepine," he said.

In the case of the short-acting triazolobenzodiazepine alprazolam (Xanax), for which difficulty in substituting other benzodiazepines has been reported, Miller recommended taking special precautions against seizures during the drug withdrawal.

"I would prefer to detoxify someone from high-dose alprazolam with phenobarbital; and I would prefer to detoxify them as an inpatient, at least initially during the peak period of seizures with alprazolam, which is the first few days," he added.

With that exception, Miller advocated utilizing outpatient programs for benzodiazepine withdrawal, while acknowledging, "It's a relatively labor-intensive monitoring...done best when the patient is engaged in other forms of therapy."