The American Society of Addiction Medicine (ASAM) is the standard-setting body for clinical care of substance use disorder patients. Their guidelines govern all parts of addiction medicine, including the most medically challenging portion of addiction treatment, the process of physically withdrawing from drugs.
This article, the second in a series of articles about ASAM standards of care, discusses the components of effective withdrawal management in addiction medicine practice.
Addiction Medicine – Standards for Physical Withdrawal
“The most effective approach to treating a patient who has withdrawal is to prescribe a long-lasting oral opioid (usually methadone or buprenorphine) to relieve symptoms and then gradually reduce the dose to allow the patient to adjust to the absence of an opioid.”
Marc A. Schuckit, M.D.
The New England Journal of Medicine
From a clinician’s perspective, managing patient withdrawal is only the first step toward recovery. Medically, it is the most difficult and risky stage of treatment. The physician tasked with overseeing the process must determine what type of pharmaceutical management is most effective: agonist, partial agonist, or antagonist maintenance.
ASAM provides three key standards for assessing and managing withdrawal in addiction treatment settings:
- Assessment
ASAM standards require the addiction medicine physician to first assess the patient’s current status when presenting for treatment. Determining how intense the withdrawal symptoms may be will help guide the physician’s choice of medical management options for treatment. Understanding the type of drug(s) the patient has been taking will help guide clinical treatment, including the choice of medications that might ease the patient’s withdrawal symptoms.
- Providing Medical Interventions
ASAM recommends the clinician utilize validated clinical measurements of the level of patient intoxication. Clinicians are also encouraged to use an evidence-based methodology to define their selection and the dosages of withdrawal management medications. The standards remind clinicians to assess and monitor for possible drug interactions. Careful documentation of all decision-making during this process is recommended, as well as developing a treatment plan.
- Psychosocial Interventions
Concurrent to medical interventions, the guidelines recommend psychosocial intervention in the form of comforting communication and clinical education during the withdrawal process.
While these are general standards of care, other governing bodies, such as the World Health Organization (WHO) provide additional guidelines that may be helpful for addiction treatment.
WHO Guidelines for Addiction Treatment of Withdrawal
The WHO Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings offers clinicians additional guidelines for the treatment of withdrawal symptoms, including:
- Healthcare should be available 24-hours a day during the process of patient withdrawal and the patient should be segregated from patients who have already completed withdrawal.
- Noting that counseling or any sort of physical exercise should not be attempted during withdrawal.
- Providing ways to cope with a combative patient by using behavioral techniques.
- Providing a short opioid withdrawal scale tied to a suggested withdrawal management regimen.
SAMHSA also offers additional clinical guidelines for withdrawal management in addiction treatment including recommendations for dispersal of buprenorphine and naloxone treatment.
Addiction treatment physicians must adhere to these clinical guidelines both as an ethical imperative and as a medical necessity.
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