7 Signs that Outpatient Detox Might Be Right for Your Patient (or You)

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?The Achilles heel of so many providers. Why is this such a dreaded and complex topic for us? Evaluating and determining disposition and treatment options for alcohol or substance withdrawal can be complicated and time consuming. In addition, for many individuals who cannot afford to go inpatient, treatment options are limited. Adding to the pressure that providers feel is the disconcerting but accurate fact that detox from alcohol and certain substances can be life-threatening. When faced with limited appointment time, limiting training on Addiction medicine, and high stakes for the patient, many providers just tell their patients to go directly to the ER to get evaluated. While understandable, this guidance unfortunately results in a perpetual merry-go-round of overflooded ERs with long waits, very limited (if any) addiction treatment, and almost inevitable returns to substance use.

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Surprisingly, only about 10% of patients need an inpatient level of care for alcohol use disorder treatment. Of those 10%, only about 1-3% develop delirium tremens-the most serious and potentially life-threatening clinical syndrome associated with very severe alcohol withdrawal. Doing the math, that means that 90% of your patients needing alcohol withdrawal care can be treated safely and successfully on an outpatient basis. Why is this important? Well, offering safe and doable treatment alternatives significantly increases the likelihood that your patient will actually follow-through. Higher follow-through is correlated with increased provider-patient rapport and better treatment outcomes, including longer lengths of sobriety, reduced use, and increased recovery capital. It’s a win win!

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To help you navigate these decisions, I’ve summarized 7 key characteristics that indicate your patient might be an appropriate candidate for an outpatient substance use disorder detox:

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7. Mild to moderate withdrawal symptoms when trying to cut down or stop use

The detox process can include a wide range of symptoms based on your patient’s length of use, frequency of use, and average consumption amount. The signs and symptoms experienced during a prior detox can be a fairly reliable predictor of how the body might experience a future detox. For this reason, be sure to get a detailed history of what your patient’s prior detoxes have looked like, including longest period without use, how long before withdrawal symptoms set up, and any notable past complications like withdrawal seizure or need for inpatient admission. If your patient has a history of uncomfortable but mild withdrawal symptoms including nausea, headache, sweating, cravings, diarrhea, muscle aches, anxiety, or insomnia, outpatient detox could be a good fit for them. If they’ve had withdrawal seizures, prominent confusion or hallucinations, or a hospital ICU admission when trying to stop alcohol or a substance, then an inpatient level of care is likely most appropriate.

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6. Shorter history with Addiction struggles

Longer total length of Addiction duration often leads to more serious withdrawal symptoms requiring a more intensive level of care (in-person or inpatient). If your patient has been struggling with substance abuse for less than 3-5 years, then he/she might be a good candidate for an outpatient detox.

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5. Withdrawal symptoms only from alcohol or a single substance

Withdrawing from alcohol and/or multiple substances at the same time often leads to more pronounced withdrawal symptoms, and increased risks. For example, a patient trying to stop drinking alcohol and stop using Xanax at the same time is riskier than the patient who is just stopping one or the other individually. Withdrawal from multiple central nervous system depressants at the same time often results in quicker and more pronounced autonomic hyper-activity and vital sign changes. For this reason, if your patient’s goal is detox from alcohol or one individual substance, then an outpatient detox might very well meet their medical needs.

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4. Longer duration in between use

One of the most accurate predictors of how severe withdrawal will be is how long someone can go between periods of use before they start to feel uncomfortable. If your patient needs to drink or use a substance every few hours versus every day or every few days to prevent withdrawal symptoms, then the detox experience is likely to start more quickly, progress more rapidly, and include more pronounced, higher risk symptoms like seizure potential. If your patient can go for at least a day or every few days before withdrawal sets in, they could be an ideal candidate for outpatient detox.

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3. Your patient is relatively healthy.

If your patient has limited comorbid medical or psychiatric conditions outside of Addiction, outpatient detox could be a great option. The detox period is typically a 5-7 day process that involves increased physical and mental stress on the body. If your patient has limited physical or mental conditions outside of Addiction, outpatient detox might safely and successfully meet their needs.

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2. Your patient has access to stable housing and transportation.

To be most successful with an ambulatory detox, it is crucial that your patient has a stable, reliable place to live and a dependable method of transportation for medication pick up. It also helps if they live 30 minutes or less from a hospital, in the event that symptoms escalate quickly.

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1.Your patient has a family member or friend who can stay with them through the detox process.

Having a friend or family member who can stay with your patient through the detox process for support and for medication pick up is critical. It also helps to have a reliable second narrator. This individual can be any person important in your patient’s life who is not currently struggling with alcohol or substance abuse themselves. This ally can interact with you as their healthcare provider and advocate for their needs during detox so your patient can focus on their health and recovery.

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With thoughtful screening criteria and a thorough intake process, Outpatient Detox can be a safe and effective option for many folks struggling with alcohol or substance use disorder. It allows your patient to complete the acute physical withdrawal period from the comfort, convenience, and privacy of their own home. Additionally, outpatient detox is less than one-fourth the cost of a traditional inpatient facility detox stay. It allows your patient to continue uninterrupted with most work, family, and childcare obligations, which greatly increases their changes of follow-through!

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There are many great medication management protocols for outpatient alcohol withdrawal including gabapentin and low dose benzodiazepine tapers. If you proceed with an outpatient alcohol withdrawal taper, American Society of Addiction Medicine - ASAM recommends you see your patient daily for the first 5-7 days and use at least one independently validated assessment tool (like the CIWA) to assess symptoms.

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Sometimes what we recommend our patients do is not always what our patients are able or willing to do. For the appropriate patient, an outpatient detox option allows you to provide addiction care to your patients who need it the most and might not get any treatment otherwise. In most cases, some treatment is better than no treatment at all, and still results in improved patient outcomes even at lower levels of care. Most importantly, it shows your patient that you are willing to work with them on their terms and meet them where they are at. This builds powerful, lasting patient-provider rapport. There are a growing number of treatment options with organizations that specialize in outpatient and even all virtual ambulatory detox. Click here to learn more about these options. Whichever provider pathway you choose, thank you for simply being present, willing, and caring to your patients suffering from substance use disorder. In the end, that’s what matters most.