Ambulatory withdrawal management - MyCASAT · 2019-05-08 · AMBULATORY WITHDRAWAL MANAGEMENT Alana...

AMBULATORY WITHDRAWAL MANAGEMENT

Alana Rogne RN, BSNNew Frontier Treatment Center

May 7, 2019

The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS). 1

TRAINING OBJECTIVES

• What is this level of care?

• Why is this level of care needed?

• Who is most appropriate for this level of care?

• What is the treatment process for this level of care?

• What are the goals of this level of care?The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).

2

WHAT IS AMBULATORY WM?

• According to SAMHSA, Ambulatory WM is defined as “outpatient treatment services providing for safe withdrawal in an ambulatory setting” – TIP 45

• Ambulatory is defined as “able to walk about and not bedridden; performed on or involving an ambulatory patient” – Merriam Webster

• Thus, ambulatory WM is managing acute and post-acute withdrawal symptoms in an outpatient setting


Presenter

Presentation Notes

Ambulatory withdrawal management is also a way for preparing the client to enter intensive outpatient treatment, along with providing medical treatment.

WHAT IS AMBULATORY WM?

• The ASAM Criteria outlines four levels of care treating WM:

• Level 1-WM: Ambulatory Withdrawal Management without Extended On-Site Monitoring

• Level 2-WM: Ambulatory Withdrawal Management with Extended On-Site Monitoring

• Level 3.2-WM: Clinically Managed Residential Withdrawal Management

• Level 3.7-WM: Medically Monitored Inpatient Withdrawal Management

• Level 4-WM: Medically Managed Intensive Inpatient Withdrawal Management


Presenter

Presentation Notes

With each of these we are looking at Biomedical and psychosocial needs assessment, with the number 1 goal being the safety of the client.

LEVEL 4-WM: MEDICALLY MANAGED INTENSIVE INPATIENT WITHDRAWAL MANAGEMENT

• Acute care inpatient setting or psychiatric hospital inpatient unit with 24-hour care

• Provides services to those whose symptoms are severe enough to require primary medical and nursing care services

• Highly individualized biomedical, emotional, behavioral, and addiction treatment

• Hourly or more frequent nurse monitoring

• H&P completed within 12 hours of admission


Presenter

Presentation Notes

Physicians available 24/7 and they are the ones medically managing the care of the patient This level of care is for a patients with a severe comorbid psychiatric disorders. These psychiatric interventions compliment addiction interventions Highest risk acuity with this level of care. Again we are looking at the client’s biomedical and psychosocial needs for safety In level 4 patients are at highest risk for DT’s and dehydration, IV administration of fluids and medication will most likely be needed. Once risk has stabilized, then transition down to lower level of care is done

LEVEL 3.7-WM: MEDICALLY MONITORED INPATIENT WITHDRAWAL MANAGEMENT

• Provides 24-hour evaluation and withdrawal management in a facility with inpatient beds – free standing withdrawal management center

• Signs and symptoms are significant enough to require 24-hour care

• Full resources of an acute care general hospital are not necessary

• Individualized biomedical, emotional, behavioral, and addiction treatment

• Hourly or more frequent nurse monitoring and medication administration/self-administration

• H&P completed within 24 hours of admission


Presenter

Presentation Notes

Physicians available 24/7 however they don’t necessarily manage the medical care of the patient – the nursing staff can medically manage the patient. Lower risk acuity or rating for this level of care Once risk has stabilized, then transition down to lower level of care

LEVEL 3.2-WM: CLINICALLY MANAGED RESIDENTIAL WITHDRAWAL MANAGEMENT

• Clinically managed residential withdrawal management – social setting detoxification/social detox

• Emphasis on peer and social support rather than medical and nursing care

• Safely assist patient through withdrawal without the need for onsite medical staff 24hours/day – access to medical evaluation and consultation if needed

• Self-administration of medications – frequently use over the counter medications

• Individualized emotional, behavioral, and addiction treatment

• Nurse assessment within 24 hours

• H&P completed prior to admission


Presenter

Presentation Notes

24 hour observation occurs, however the observation is conducted by appropriate trained staff, such as Certified Detoxification Technicians and licensed clinicians. Lower risk acuity or rating than 4 and 3.7 Know your institutions policy and procedure Possible standing orders for the nurse Work closely with you local hospital This is an important level for understanding the difference between Intoxication and WM. Those that are intoxicated can be volatile Once risk has stabilized, transfer to lower level of care

LEVEL 2-WM: AMBULATORY WITHDRAWAL MANAGEMENT WITH EXTENDED ON-SITE MONITORING

• Withdrawal management is delivered in an office setting, health/mental health facility, or an addiction treatment facility

• Medical and nursing professionals conduct evaluations and WM in daily scheduled sessions

• Staffed by physicians and nurses however they don’t need to be present 24/7 – available for consultation if needed

• Individualized biomedical, emotional, behavioral, and addiction treatment

• Daily assessment of progress during withdrawal management – medication or non-medication methods



Presenter

Presentation Notes

WM is facilitated on an outpatient basis Medical and nursing staff need to medically confirm the patient will be safe while being managed in a less supervised setting Drug testing and vitals tracking for client safety. Client readiness is crucial Prescriber on hand for possible MAT treatment Ideally the facility would have some kind of transportation program that would assist the patient with any transportation barriers – vans, bus passes, taxi vouchers, etc. Lower risk acuity or rating than 4, 3.7, 3.2 Once risk has stabilized, transfer to lower level of care

LEVEL 1-WM: AMBULATORY WITHDRAWAL MANAGEMENT WITHOUT EXTENDED ON-SITE MONITORING

• Organized outpatient service, delivered in an office setting, health care/addiction treatment facility, or in a patient’s home

• Physicians and nurses staff this level of service

• Assessment of progress during withdrawal management – medication or non-medication methods

• Frequency of scheduled sessions are determined by severity of withdrawal symptoms

• Patient has a sufficient/stable support system (family) who can assist with monitoring symptoms



Presenter

Presentation Notes

If this level of care is going to be provided within the patient’s home then it needs to be facilitated by trained clinicians who provide medically supervised evaluations, withdrawal management, and referral services according to a predetermined schedule and medical protocols Will your facility do MAT Daily Vital checks Drug testing Medications prescribed based on facility protocol, what can your facility feasibly accomplish Client readiness is crucial Medical and nursing staff need to medically confirm the patient will be safe while being managed in a less supervised setting Ideally the facility would have some kind of transportation program that would assist the patient with any transportation barriers – vans, bus passes, taxi vouchers, etc. Lower risk acuity or rating than 4, 3.7, 3.2, 2 Once risk has stabilized, transfer to lower level of care

WHY IS AMBULATORY WM NEEDED?

• Opioid use and misuse continues to increase

• CDC reports 91 Americans die from opioid overdose and approximately 50 Americans die from alcohol use everyday

• Efficacy and efficiency of Medication Assisted Treatment has been proven


Presenter

Presentation Notes

July 2016 Codified ruling in the Code of Federal Regulations – Increase access to MAT services by allowing eligible practioners to treat up to 275 patients instead of the previous capped amount of 100 patients. MAT studies have shown: patients relapse less often, which in turn reduces the risk of death by overdose; increases treatment retention; Improves social functioning; Reduces the risks of infectious-disease transmission; Reduces criminal activity Understand your clients

WHY IS AMBULATORY WM NEEDED?


Presenter

Presentation Notes

This is a picture of what opiate withdrawal feels like when quitting cold turkey – ambulatory withdrawal management through medication assisted treatment can help prevent the patient from feeling this sick – thus, reducing their cravings and relapse potential

WHO IS APPROPRIATE FOR AMBULATORY WM?

• Ambulatory WM may be appropriate for individuals suffering from alcohol, nicotine, opioid, sedative/hypnotic, and stimulant use disorders

• Level of care is based on risk severity and ratings – per ASAM

• Thorough assessment of withdrawal symptoms must be completed before recommendation and admission


Presenter

Presentation Notes

ASAM pages 147 – 164 – risk rating matrix that assists providers with determining the risk severity ASAM pages 165 – 173 – provides Withdrawal Management Decision Rules in Continuum, The ASAM Criteria Decision Engine. This Continuum assists providers in determining the most appropriate level of care based on the presence of withdrawal symptoms and the other five dimensions. Those that have a supportive environment It is client/patient driven Comorbidities Do they need medications and what is your facilities ability to monitor the client.

WHAT IS THE TREATMENT PROCESS FOR AMBULATORY WM?

• Regular Office Visits• Daily for 2-WM - extended on-site monitoring• Every few days or as determined by provider and patient for 1-WM – w/o on-site

monitoring

• Withdrawal Symptoms Assessment – CIWA-AR; COWS; CINA; and FagerstromTest

• Medication Assessment – initial then reassessment of treatment goals/service needs – adjustment and taping of medications

• Drug Screens

• Therapy and/or other psychosocial services


Presenter

Presentation Notes

CIWA-AR – Clinical Institute Withdrawal Assessment for Alcohol-Revised COWS - Clinical Opiate Withdrawal Scale CINA – Clinical Institute Narcotic Assessment Scale These four tools are to be used in conjunction with other assessment measures and should not be used as the primary and sole decision making tool for symptom assessment and admission justification

WHAT ARE THE GOALS OF AMBULATORY WM?

• Stabilization

• Manage Withdrawal Symptoms

• Eliminate Illicit Use

• Reduce relapse potential

• Reduce readmission to intensive levels of service


CONCLUSION

• Thorough assessment of all six dimensions is crucial to patient placement

• Thorough assessment of present withdrawal symptoms as well as the risk of withdrawal symptoms is crucial to patient placement

• MAT is an effective intervention that assists with making 1-WM and 2-WM successful

• 1-WM and 2-WM can be woven into other treatment programs/levels of care


REFERENCES• Centers for Disease Control - Opioid Overdoses:

https://www.cdc.gov/drugoverdose/epidemic/index.html

• Centers for Disease Control - Alcohol Deaths: https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm

• Center for Substance Abuse Treatment. Detoxification and Substance Abuse Treatment.Treatment Improvement Protocol (TIP) Series 45. DHHS Publication No. (SMA) 06-4131. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006.


https://www.cdc.gov/drugoverdose/epidemic/index.html

https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm

REFERENCES• Mee-Lee, David. (Eds.) (2013) The ASAM criteria :treatment for addictive, substance-

related, and co-occurring conditions Chevy Chase, Md. : American Society of Addiction Medicine.

• Volkow, N. D., et al. (2014). “Medication-Assisted Therapies – Tackling the Opioid-Overdose Epidemic.” N Engl J Med.


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Ambulatory withdrawal management - MyCASAT · 2019-05-08 · AMBULATORY WITHDRAWAL MANAGEMENT Alana...

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