Models of intervention and care for psychostimulant users, 2nd edition - monograph series no. 51

Decision tree for the management of psychostimulant detoxification

Page last updated: April 2004

Diagram. Decision tree for the management of psychostimulant detoxification

Text equivalent below for Diagram: Decision tree for the management of psychostimulant detoxification
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Text version of Diagram

Assessment for psychostimulant dependence and risk of withdrawal:
  1. average daily intake (in $, shots, tablets, snorts)
  2. frequency of use (daily? binges?)
  3. duration of use (months or years?)
  4. type of psychostimulant used
  5. route of administration (intravenous use more problematic)
  6. time/day of last use
  7. other drug use (are they dependent?)
  8. history and severity of withdrawal symptoms & treatment
  9. history of psychotic illness (risk of psychosis increases with duration of use and potency of psychostimulant)
  10. history of depressive illness or suicidal ideation
  11. 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
Continue to 'Suitable for Home/Ambulatory Detoxification?'
Severe Dependence?
  • 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
Continue to 'Hospital or Specialist Detoxification Facility' Top of page
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
Yes, continue to 'Initial Management Plan'

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
Yes, continue to 'Management'
Initial Management Plan
  1. implement daily review
  2. closely monitor mood
  3. give symptomatic relief if necessary (small dose of benzodiazepine to restore sleep; paracetamol for body aches; encourage fluid intake; possibly antidepressant if necessary)
  4. adjunctive supportive therapies such as relaxation techniques, CBT for anxiety/depression symptom management, education re withdrawal, early relapse prevention strategies, motivational enhancement
Continue to 'Detoxification Completed?' or 'Protracted or Complicated Detoxification?'
Management
  1. admit to a medically supervised setting (may be psychiatric setting if psychosis is severe)
  2. management of withdrawal will proceed according to specific client needs and according to existing protocols followed by that unit.
  3. simultaneous management by mental health and alcohol and other drug treatment providers may be required.
Continue to 'Detoxification Completed' Top of page
Detoxification Completed?
  1. intensity of symptoms subsides by about week 4
  2. education regarding mood monitoring / possibility of enduring symptoms that should be manageable in the community
  3. continue relapse prevention strategies
  4. encourage continuation of psychosocial interventions
  5. encourage continuation of adequate diet, fluids
Protracted or Complicated Detoxification?
  1. not sleeping with small dose benzodiazepine
  2. increasing scores on Observation Scale over 10–14 days
  3. increasing agitation, distress, paranoia, depression, suicidal ideation or psychotic symptoms that cannot be safely managed in the community
  4. intense cravings to use amphetamines
  5. person believes they cannot complete detoxification in the community
Continue to 'Management'
Management
  1. 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.
Continue to 'Detoxification Completed'
Detoxification Completed
  1. intensity of withdrawal symptoms diminishing
  2. mood fairly stable
  3. initiate follow-up and/or referral to specialist alcohol and drug services or community agencies for relapse prevention/psychosocial interventions/supportive care