Diagram. Decision tree for the management of psychostimulant detoxification
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Text version of DiagramAssessment for psychostimulant dependence and risk of withdrawal:
- average daily intake (in $, shots, tablets, snorts)
- frequency of use (daily? binges?)
- duration of use (months or years?)
- type of psychostimulant used
- route of administration (intravenous use more problematic)
- time/day of last use
- other drug use (are they dependent?)
- history and severity of withdrawal symptoms & treatment
- history of psychotic illness (risk of psychosis increases with duration of use and potency of psychostimulant)
- history of depressive illness or suicidal ideation
- current mental health status
Decision tree flow chart
Mild to Moderate Dependence?
- no history of severe/complicated withdrawal
- no significant poly substance dependence
- not spending large amounts of money on the drug
- symptoms of psychosis or depression, if present, can be adequately and safely managed in the community
- history of severe/complicated withdrawal
- significant poly substance dependence
- protracted duration of use of high doses
- uses potent type of psychostimulants
- uses intravenously
- high tolerance for the drug — uses only to feel 'normal'
- history of severe depression/suicidal ideation/severe psychosis
Suitable for Home/Ambulatory Detoxification?
- no previous complicated/severe withdrawal
- not severely dependent
- no indication of concomitant medical or psychiatric illness, injury or recent surgery that could not be safely managed in the community
- the person has a stable home environment where psychostimulants are not available
No, continue to 'Management'
Hospital or Specialist Detoxification Facility?
- previous complicated withdrawal with severe depression or psychosis that required management in a hospital setting
- assessed as severely dependent
- concomitant psychiatric or medical illness, injury or recent surgery that cannot be safely managed in the community
- dependence on alcohol or other drugs that would in itself meet criteria for admission
- the person has no stable home environment or is homeless
- the person has access to, or is exposed to psychostimulants in their home environment
Initial Management Plan
- implement daily review
- closely monitor mood
- give symptomatic relief if necessary (small dose of benzodiazepine to restore sleep; paracetamol for body aches; encourage fluid intake; possibly antidepressant if necessary)
- adjunctive supportive therapies such as relaxation techniques, CBT for anxiety/depression symptom management, education re withdrawal, early relapse prevention strategies, motivational enhancement
- admit to a medically supervised setting (may be psychiatric setting if psychosis is severe)
- management of withdrawal will proceed according to specific client needs and according to existing protocols followed by that unit.
- simultaneous management by mental health and alcohol and other drug treatment providers may be required.
- intensity of symptoms subsides by about week 4
- education regarding mood monitoring / possibility of enduring symptoms that should be manageable in the community
- continue relapse prevention strategies
- encourage continuation of psychosocial interventions
- encourage continuation of adequate diet, fluids
Protracted or Complicated Detoxification?
- not sleeping with small dose benzodiazepine
- increasing scores on Observation Scale over 10–14 days
- increasing agitation, distress, paranoia, depression, suicidal ideation or psychotic symptoms that cannot be safely managed in the community
- intense cravings to use amphetamines
- person believes they cannot complete detoxification in the community
- admit to hospital or detoxification facility if possible in an effort to assist person to complete detoxification, monitor mood, and undergo psychiatric assessment if indicated. May require short-term antipsychotic medication treatment or containment in a place of safety if severe.
- intensity of withdrawal symptoms diminishing
- mood fairly stable
- initiate follow-up and/or referral to specialist alcohol and drug services or community agencies for relapse prevention/psychosocial interventions/supportive care