The Principles of Detoxification

Presented by: Theresa Lemus, MBA, BSN, LADC

Quick Guide for Clinicians Based on TIP 45

Detoxification and Substance Abuse Treatment

TIP 45 Detoxification and Substance Abuse

Treatment (free resource)

American Society of Addiction Medicine’s

Patient Placement Criteria 2-Revised

Diagnostic and Statistical Manual IV TR

Resources

To inform participants about the basic principles of withdrawal from alcohol and other drugs and to help participants understand their role in caring for persons in a community-based detoxification setting

To help participants meet the legal requirements for detox providers

Purpose of the Course

After completion of this class participants will:1. Understand the laws and regulations that govern social and

modified medical model detoxification programs in Nevada (NRS)

2. Have improved knowledge of the biopsychosocial aspects of withdrawal (signs and symptoms, ASAM dimensions)

3. Have knowledge of the most common medications used in withdrawal management

4. Understand the parameters and limitations of a social model setting (NRS, medications, care coordination)

5. Understand their role in providing care in a detox setting (limitations, guidelines, engagement, retention, NHIPPS)

6. Understand and successfully demonstrate how to measure, record and report vital signs

7. Have met one of the legal requirements established in NRS for detox providers

Goals

Nevada Administrative Code, Chapter 449 for Medical and Other Related Facilities- The Bureau of Health Care Quality and Compliance formerly Bureau of Licensure and Certification

Nevada Revised Statutes, Chapter 458- SAPTA

Nevada Revised Statutes, Chapter 641C - Alcohol, Drug And Gambling Counselors And Detoxification Technicians- Board of Examiners for Alcohol, Drug, and Gaming Counselors

Detox Laws and Regulations

Education / training (this class) initially and every two years

Seizure care

Tuberculosis and communicable diseases

Current certification in Cardiopulmonary

Resuscitation

Pass skills test for measuring, recording and

reporting vital signs

Requirements for Detox Providers

The State Board of Health's regulations governing the control of communicable diseases are found in the Nevada Administrative Codes (NAC) Chapter 441A

These regulations mandate public health professionals, medical providers, laboratories and others in Washoe County to report approximately 50 diseases or conditions to the District Health Department Communicable Disease Program.

All reported information is CONFIDENTIAL.

Communicable Disease Reporting

Prior to the 1970’s public intoxication was commonly treated as a criminal offense. Drunk tanks, withdrawal with no medical intervention.

From this- arose the medical model and social models of detoxification.

Detoxification

According to the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Administration (SAMHSA) detoxification is a set of interventions aimed at managing acute intoxication and withdrawal.

Clearing of toxins from the body. The primary goal is to build a therapeutic

alliance and motivate clients to enter treatment.

Definition- Detoxification

Social Model Programs

Social model substance abuse treatment

programs concentrate on providing psychosocial services.

Trained detox personnel and other clinicians provide supportive withdrawal management services in addition to individual and family counseling and coordination of care.

A clinically managed residential detoxification that may be delivered by appropriately trained staff, who provide 24-hour supervision, observation and support for patients who are intoxicated or experiencing withdrawal.

Clinically managed detoxification is characterized by

its emphasis on peer and social support. Intoxication and withdrawal signs and symptoms are sufficiently severe enough to require 24-hour structure and support but not severe enough to warrant the resources of a Level III.7-D medically monitored inpatient detoxification.

ASAM Level III.2D Social Detox

Medically monitored inpatient detoxification is an organized service delivered by medical and nursing professionals, which provides for 24 hour medically supervised evaluation and withdrawal management in a permanent facility with inpatient beds. Services are delivered under a defined set of physician-approved policies and physician monitored procedures or clinical protocols.

ASAM III.7D Modified Medical Detox

Modified and full medical detox can be characterized by:

directed by a physician staffed by other health care personnel range from hospital-based inpatient programs to

free-standing medically based residential programs in hospitals or in community facilities

can draw on various medical resources within the community

designed to treat more serious substance withdrawal syndromes that require the use of detox medications and medical oversight

Medical Model Detoxification

1. Evaluation2. Stabilization3. Fostering client readiness for and entry into

treatment

*a detox process that does not incorporate all three critical components is considered incomplete and inadequate

Three Components of Detox

NHIPPS -- Treatment Flowchart

SOCIAL MODEL DETOX EPISODE

revised 09/08 - MMD / SAPTA

Develop detox treatment plan (not the NHIPPS treatment plan) to

address ASAM withdrawal dimension Detox TX plan can be recorded in Chart Note

Complete one NHIPPS Progress Note per day Monitor for withdrawal symptoms, record vitals

and observations in NHIPPS Chart Note or paper file

TX plan should engage client, monitor withdrawal symptoms and medications, and introduce client to

individual or group therapeutic events .

Progress Note should include observation, vitals summary, engagement attempts,

client participation and readiness for care

TREATMENT

Once client has adequately completed detox, review

assessment and mark it complete

Create Discharge Record – refer to

appropriate level of care

DISCHARGE / TRANSFER

Complete discharge HDPC

Open completed discharge record in the activity list to access discharge HDPC

Complete within 5 days of actual client discharge

Complete Admission Record for ASAM Level III.2DADMISSION / ASSESSMENT

Ensure Client has medical clearance for

SM Detox

Ensure client has had a drug test

Establish diagnosis and check for

prescription or OTC detox medication

INTAKEClient presents for SM detox service

Clearance can be granted by ER or other qualified medical

personnel

Lab license required for testing. Testing is critical to identify drug used, determine diagnosis, increase client safety and

reduce agency liability

Search for Client Profile in NHIPPS, if none exists, create a

new profile record

Any staff with chart entry privileges can do this if a diagnosis has been established

Complete NHIPPS assessment including HDPC within 24 hours of admission

Note in HDPC clinical summary that only ASAM Intoxication / Withdrawal is the driving dimension

The assessment may be left “in progress” so it can be reviewed when client is admitted to the next level of care or if the client does not stay to complete the assessment

Goal is 40% engagement in continued care after detox

Complete intra or inter agency transfer steps (Client must consent to inter-agency transfer of his / her

records)

The American Society of Addiction Medicine Patient Placement Criteria 2nd Edition Revised (ASAM-PPC-2R) is the evidenced-based literature referenced in support of the Health Division Placement Criteria required by SAPTA.

Patient (Client) Placement into a Level of Service

Client Placement

The placement criteria describe levels of treatment that are differentiated by the following characteristics:

(1) degree of direct medical management provided,

(2) degree of structure, safety, and security provided, and

(3) degree of treatment intensity provided.

Dimensional CriteriaDimension 1

Acute Intoxication &/or Withdrawal

Potential

Dimension 2 Biomedical

Conditions & Complications

Dimension 3 Emotional,

Behavioral, or Cognitive

Conditions & Complications

Dimension 4 Readiness to

Change

Dimension 5 Relapse,

Continued Use or Continued

Problem Potential

Dimension 6 Recovery / Living

Environment

Dimension 1- Acute Intoxication &/or Withdrawal Potential

The Goals of Care:1. Avoidance of potentially

hazardous consequences of discontinuation

2. Facilitation of the client’s completion of detoxification

3. Promotion of client dignity

Dimension 2-Biomedical Conditions & Complications

Are there current physical illnesses?

Are there chronic conditions that affect treatment?

Persons undergoing withdrawal are in

profound medical and personal crisis!

Withdrawal can cause and/or exacerbate

physical, emotional, psychological or mental

problems.

Biopsychosocial Factors of Withdrawal from AOD

NAC 449.1214 Medical Clearance requires a physical assessment/exam by an MD, PA, NP, or RN within 24 hours to ensure that a social model is appropriate◦ Diagnosis◦ Detox medications◦ Special instructions

Clients are provided with continuous monitoring based upon established written and MD approved policies and procedures(see sample)

*Drug test Comply with NAC 449.144 Medications

*Not yet required but preferred

Requirements for Admittance to Social Model Detox in Nevada

Initial Evaluation

Biomedical Psychosocial

General health history Mental status General and physical

assessment and neuro check

Vital signs Patterns of use Urine toxicology Past treatment or

withdrawal

Demographics Living conditions Violence/suicide risk Transportation Financial situation Dependent children Legal status Physical, sensory or

cognitive disabilities

Medication Review & Assist

NAC 449.144 “Medication Assist”

Medication assist Right container Labeled

◦ Client name◦ Medication◦ Dosage◦ Instructions◦ Prescribing physician◦ Not expired!

Detox staff make medication available◦ Observe◦ Document◦ Monitor◦ Contact prescribing or

ER physician as needed

Change in mental statusIncreasing anxietyHallucinationsTemperature greater than 100.4 (infectious)Significant increase/decrease in vitalsInsomnia-prolongedUpper and lower GI bleedingChange in responsiveness- pupilsHeightened deep tendon reflexes

*Immediate MH needs: Suicidality, Anger and Aggression 

Symptoms and Signs Requiring Immediate Medical Attention

Homeostasis-A state of equilibrium

Brains

have been Re-Wired by Drug Use

Brains

have been Re-Wired by Drug Use

DRUG ADDICTION IS A COMPLEX ILLNESS

www.drugabuse.gov

One of the neurotransmitters playing a major role in addiction is dopamine.

As a chemical messenger, dopamine is similar to adrenaline.

Dopamine affects brain processes that control movement, emotional response, and ability to experience pleasure and pain.

Regulation of dopamine plays a crucial role in our mental and physical health.

Dopamine

Your Brain on Drugs

1-2 Min 3-4 5-6

6-7 7-8 8-9

9-10 10-20 20-30

Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377.

Your Brain After Drugs

Normal

Cocaine Abuser (10 days)

Cocaine Abuser (100 days)

Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.

Drugs HaveLong-term Consequences

Photo courtesy of NIDA from research conducted by Melega WP, Raleigh MJ, Stout DB, Lacan C, Huang SC, Phelps ME.

The Memory of Drugs

Nature Video Cocaine Video

Front of Brain

Back of Brain

Amygdalanot lit up

Amygdalaactivated

Photo courtesy of Anna Rose Childress, Ph.D.

Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH)

Abuser After Protracted Abstinence

Normal Control METH Abuser(1 month detox)

METH Abuser(24 months detox)

0

3

ml/gm

Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.

Pharmacologic therapies are indicated for

use in persons with substance use disorders

to prevent life-threatening withdrawal

complications such as seizures and delirium

tremens, and to increase compliance with

psychosocial forms of addiction treatment.

Pharmacotherapy for Withdrawal Syndromes

Methamphetamine Methamphetamine is a powerful central nervous

system stimulant that strongly activates multiple systems in the brain. Methamphetamine is closely related chemically to amphetamine, but the central nervous system effects of methamphetamine are greater.

Methamphetamine causes a tremendous release of dopamine into the synapse and causes displacement in little sacs of the dopamine transmitters.

Forms of Methamphetamine

Methamphetamine Powder

Description: Beige/yellowy/off-white powder

Base / Paste Methamphetamine

Description: ‘Oily’, ‘gunky’, ‘gluggy’ gel, moist, waxy

Crystalline Methamphetamine

Description: White/clear crystals/rocks; ‘crushed glass’ / ‘rock salt’

Methamphetamine The effects of methamphetamine include increased activity,

decreased appetite, and a sense of well-being that can last from six to eight hours.

The drug has limited medical uses for the treatment of narcolepsy, attention deficit disorders, and obesity.

Increase wakefulness and physical activity and decrease appetite.

Methamphetamine can also cause a variety of cardiovascular problems, including rapid heart rate, irregular heartbeat, and increased blood pressure. Hyperthermia (elevated body temperature) and convulsions may occur with methamphetamine overdose, and if not treated immediately, can result in death.

(National Institute on Drug Abuse, Methamphetamine: Abuse and Addiction, April 1998.)

Methamphetamine Long Term Effects Anxiety Confusion Insomnia Mood disturbances Violent behavior

Psychotic features, including paranoia, visual and auditory hallucinations, and delusions (for example, the sensation of insects creeping under the skin). Psychotic symptoms can sometimes last for months or years after methamphetamine abuse has ceased, and stress has been shown to precipitate spontaneous recurrence of methamphetamine psychosis in formerly psychotic methamphetamine abusers.

Peak period: 1-3 days after cessation

Duration: 5–7 days depending on various factors

Signs: Social withdrawal, psychomotor retardation, hypersomnia, hyperphagia

Symptoms: Depression, anhedonia, suicidal thoughts and behavior, paranoid delusions

Signs and Symptoms of Methamphetamine Withdrawal

Marijuana Peak period: 24 hours after cessation

Duration: 5–7 days depending on various factors

Signs: Anxiety, Restlessness, Irritability, Sleeplessness

Symptoms: Depression

Management of alcohol withdrawal is based on the client’s history and current clinical status. The single best predictor of the likelihood of future withdrawal symptoms when alcohol is concerned is the patient's previous history, e.g., the presence or absence of seizures or delirium tremens

Alcohol

Peak period: 1-3 days after cessation Duration: depends on various factors Signs: Elevated blood pressure, pulse and

temperature, hyperarousal, agitation, restlessness, cutaneous flushing, tremors, diaphoresis, dilated pupils, ataxia, clouding of consciousness, disorientation

Symptoms: Anxiety, panic, paranoid delusions, illusions, visual and auditory hallucinations (often derogatory and intimidating)

Signs and Symptoms of Alcohol Withdrawal

Pharmacology of Withdrawal from Alcohol

Valium- (Diazepam) is a benzodiazepine with a medium to long duration of action. Used for withdrawal to decrease blood pressure, to relieve anxiety, to help relax muscles or relieve muscle spasm.

Ativan- (Temesta or Lorazepam) is a benzodiazepine with short to medium duration of action.

Atenolol – (Tenormin) is a beta-blocking agent used in the treatment of high blood pressure, used to relieve angina, and in heart attack patients to help prevent additional heart attacks. It is also used to correct irregular heartbeat, prevent migraine headaches, and to treat tremors.

Clonidine (Catapres)- lowers blood pressure by decreasing the levels of certain chemicals in your blood. Reduces anxiety.

At the first sign- summon trained medical personnel

Prevent injury-protect head, move nearby objects

Place on side if client is vomiting Soothing, calm voices/actions Medical Evaluation!

Seizures

Is a potentially fatal form of alcohol withdrawal.

Symptoms may begin a few hours after the cessation of ethanol but may not peak until 48-72 hours. Emergency Room Physicians must recognize that the presenting symptoms may not be severe and identify those at risk for developing DT. For patients in DT, early recognition and therapy are necessary to prevent significant morbidity and death.

Delirium Tremens

Management of withdrawal can be accomplished with medications to alleviate symptoms

Opiates

Peak period: 1-3 days after cessation Duration: 7-14 days depending on various

factors Signs: Drug seeking, mydriasis, piloerection,

diaphoresis, rhinorrhea, lacrimation, diarrhea, insomnia, elevated blood pressure and pulse (mild)

Symptoms: Intense desire for drugs, muscle cramps, arthralgia, anxiety, nausea, vomiting, malaise

Signs and Symptoms of Opiate Withdrawal

Represent a diverse class and include sedative-hypnotics, stimulant and hallucinogens

Clubs/raves Adolescent/young adult

Club Drugs

Common household products that give off mind-altering chemical fumes when sniffed

Paint thinner, fingernail polish remover, glues, gasoline, cigarette lighter fluid, and nitrous oxide, whipped cream, hair and paint sprays, and computer cleaners

The chemical structure of the various types of inhalants is diverse, making it difficult to generalize about the effects of inhalants.

Inhalant users are also at risk for Sudden Sniffing Death (SSD), which can occur when the inhaled fumes take the

place of oxygen in the lungs and central nervous system.

Inhalants

Withdrawal from benzodiazepines such as Xanax, Librium, Ativan, etc. cannot be managed in a social model detox setting

Withdrawal must be overseen by a physician

Detox can be done on an outpatient basis

Benzodiazepines

NHIPPS -- Treatment Flowchart

SOCIAL MODEL DETOX EPISODE

revised 09/08 - MMD / SAPTA

Develop detox treatment plan (not the NHIPPS treatment plan) to

address ASAM withdrawal dimension Detox TX plan can be recorded in Chart Note

Complete one NHIPPS Progress Note per day Monitor for withdrawal symptoms, record vitals

and observations in NHIPPS Chart Note or paper file

TX plan should engage client, monitor withdrawal symptoms and medications, and introduce client to

individual or group therapeutic events .

Progress Note should include observation, vitals summary, engagement attempts,

client participation and readiness for care

TREATMENT

Once client has adequately completed detox, review

assessment and mark it complete

Create Discharge Record – refer to

appropriate level of care

DISCHARGE / TRANSFER

Complete discharge HDPC

Open completed discharge record in the activity list to access discharge HDPC

Complete within 5 days of actual client discharge

Complete Admission Record for ASAM Level III.2DADMISSION / ASSESSMENT

Ensure Client has medical clearance for

SM Detox

Ensure client has had a drug test

Establish diagnosis and check for

prescription or OTC detox medication

INTAKEClient presents for SM detox service

Clearance can be granted by ER or other qualified medical

personnel

Lab license required for testing. Testing is critical to identify drug used, determine diagnosis, increase client safety and

reduce agency liability

Search for Client Profile in NHIPPS, if none exists, create a

new profile record

Any staff with chart entry privileges can do this if a diagnosis has been established

Complete NHIPPS assessment including HDPC within 24 hours of admission

Note in HDPC clinical summary that only ASAM Intoxication / Withdrawal is the driving dimension

The assessment may be left “in progress” so it can be reviewed when client is admitted to the next level of care or if the client does not stay to complete the assessment

Goal is 40% engagement in continued care after detox

Complete intra or inter agency transfer steps (Client must consent to inter-agency transfer of his / her

records)

Client Profile • Profile record should be the first or

bottom record in the client activity list – this is controlled by profile date

• Always assume there is a profile for the client before creating one – in other words, search for a profile before entering a new one

• If your agency has multiple treatment locations where intake could occur, techs and counselors should have access to view client records from the Business Level and should also have the ability to move to any treatment location within the system to share records with the detox treatment location

• TURN YOUR POPUP BLOCKER OFF BEFORE ENTERING A NEW CLIENT PROFILE – this way, if one already exists at your agency, the system will find it and notify you

• Enter only the city in Birth City field

Admission Record (page 1)

• Do not select Transitional Housing as the admission type for a detox admission – detox is a residential admission, transitional housing is paired with outpatient services

• Do not enter dollar signs or decimal places in monetary fields

Admission record (page 2)

Admission justification should be written by a counselor, however if a technician must enter an admission record, the justification should rely on a medical record that indicates a diagnosis of intoxication or withdrawal and can include drug and other test results and prior admissions for detox within 30 days of the current admission. The technician should contact supervisor as soon as possible to schedule a complete assessment. Example 1: Client arrived at 11:00pm, cleared through ER. ER documentation states intoxication (alcohol) diagnosis, cleared for social detox. Example 2: Client assessed by Dr. Jones, medically cleared with intoxication diagnosis for social detox treatment.

Detox TX Plan (Chart Note)

• Chart note is accessed from the toolbar in the Client Activity List screen• Exercise care when entering information in the Chart Note as it cannot be deleted • If creating a treatment plan for detox, enter Detox TX Plan for as the topic

Screening

• The screening record contains questions about gambling behavior and should be completed

• The screening score is not the justification for an assessment, it is a tool to be used by a provider to establish a business process

Assessment / General - Leave In Progress

• Leave the assessment in progress for clinical staff at the next level of care to review and modify if necessary

Assessment / Substance

Assessment / HDPC (ASAM)

• If the HDPC record is idle for more than 5 minutes, it is advisable to copy the clinical summary before saving the record. This will ensure that if the current NHIPPS session is terminated, the text entered into the clinical summary field will be stored on the computer Clipboard and can be copied back into this record

Client Engagement & Retention

Treatment Improvement Protocol Series (35), 1999 87

The Stages of Change

Precontemplation Contemplation Preparation Action Maintenance Recurrence

Readiness to Change

Reflects Prochaska & DiClemente’s “Stages of Change Model”

An individual’s emotional and cognitive awareness of the need to change and his or her level of commitment to and readiness for change indicate his or her degree of cooperation with treatment…

TIPS 35, 1999 89

The Stages of Change

Precontemplation- The substance use has

not considered change and does not plan to make changes in the near future. The may be partly or completely unaware that the problem even exists.

Strategies- Rapport & trust building, raise doubts or concerns, elicit CSO’s assistance.

TIPS 35, 1999 90

The Stages of Change Contemplation client is aware of the

problem and starts to examine the possibility of change. These are individuals who are ambivalent (seeing reasons to change and at the same time seeing reasons not to change). They are sitting on a teeter-totter. The “Ya, but..”

Strategies- Normalize the ambivalence, elicit self-motivation statement from the client, “tip” the scale.

TIPS 35, 1999 91

The Stages of Change Preparation- The individual can see the

advantages to change and is aware that they outweigh the disadvantages. They have a strengthened commitment to change and may have even set a date to quit use or have decreased their use. It’s a window that opens for a short period.

Strategies- Clarify goals, offer a menu of options, negotiate strategies for change, help client to enlist social support, make a public announcement.

TIPS 35, 1999 92

The Stages of Change

Action - The individual chooses strategies to change and actively works towards change. They are taking steps to change. Often they are behaviorally definable differences. However, they have not reached a stable state.

Strategies- Continue to engage and reinforce any changes with a focus on the importance of remaining in recovery, support small step, identify high-risk situations, help client assess current social support system.

TIPS 35, 1999 93

The Stages of Change

Maintenance- The individual works to

sustain any gains made during the action phase. They have achieved the initial goals towards change and now are working towards maintaining them.

Strategies- “fire-escape” plan, review long-term goals, sample drug-free sources of pleasure, role-play & practice coping skills.

TIPS 35, 1999 94

The Stages of Change

Recurrence- the client experiences a

recurrence of the symptoms and now has to face the consequences. Assist in reentry and commend any willingness

to consider continued change. Explore the recurrence as a learning experience

and learning opportunity. Elicit social support Explore alternative coping strategies.

Relapse

Relapse is an act or instance of backsliding, worsening, or subsiding, and may be the common denominator in one of the outcomes of treatments designed to address psychological problems and health-related behaviors especially those related to alcohol and drug misuse.

Vital Signs

Vital Signs

Vital signs include the measurement of: temperature, respiratory rate, pulse, blood pressure and, where appropriate, blood oxygen saturation.

Vital Signs can:

1. Identify the existence of an acute medical problem.

2. Are a means of rapidly quantifying the magnitude of an illness and how well the body is coping with the resultant physiologic stress. The more abnormal the vitals, the sicker the clients.

3. Vital signs are a marker of chronic disease states (e.g. hypertension is defined as chronically elevated blood pressure).

Taking Measurements The room should be quiet, warm and well

lit.

Prior to measuring vital signs, the clients should have had the opportunity to sit for approximately five minutes so that the values are not affected by the exertion.

All measurements are made while the client is seated.

Temperature Normal range is 96 to 99.5 degrees

Fahrenheit

Respiratory Rate Respirations are recorded as breaths per

minute They should be counted for at least 30

seconds Try to measure discretely so that the client

does not consciously alter their rate of breathing

Counting breaths can be done by observing the rise and fall of the client’s chest while you appear to be taking their pulse.

Normal range is between 12 and 20.

Pulse Generally done by palpating the radial

impulse Measure the rate of the pulse (recorded in

beats per minute). Count for 30 seconds and multiply by 2 (or

15 seconds x 4). If the rate is particularly slow or fast, it is probably best to measure for a full 60 seconds

Normal range is between 60 and 100.

Blood Pressure Blood pressure is the force of blood pushing

against the walls of arteries – the blood vessels that carry blood away from the heart to other parts of the body

Blood pressure can rise and fall depending on a person’s general health, their level of physical activity, the time of day and many other factors

Normal range is Systolic: 100 to 140. Diastolic: Equal to or less than 90

Procedures for Social vs. Medical Model Detox

Dependent on agency policies

Social Model Detox reports all abnormal vital sign measurements to licensed healthcare professionals

Medical Detox has option to medicate and treat the individual based on physician-approved protocols and physician‘s orders

Skills Test