Home or ambulatory detoxificationMost people identify the home setting as the preferred option for supervised detoxification and many might be more willing to undertake detoxification if they do not require hospitalisation (Saunders, Ward & Novak, 1997). The option to detoxify at home might be especially appealing to psychostimulant users who are often reluctant to access mainstream treatment services for reasons previously noted. In addition, as the withdrawal syndrome from psychostimulants may be protracted, a hospital setting may be inappropriate for many individuals.
During home detoxification, the person is supervised in their home by a carer and receives daily visits from a registered nurse or a general practitioner. There are several community agencies in Australia that provide this type of service. These agencies may be identified by calling the state alcohol and drug telephone information service.
During ambulatory (or outpatient) detoxification, the person attends the local drug treatment service or the local hospital (in some regional areas) daily, or sees his/her general practitioner daily or second daily.
The detoxification process should be monitored and appropriate interventions undertaken. The aim of ambulatory or home-based detoxification is to:
- manage the symptoms of withdrawal in a supportive environment;
- monitor the person's mood;
- provide an opportunity for early intervention if adverse consequences arise;
- educate people about the course of withdrawal and the likelihood of enduring symptoms;
- maintain commitment to withdrawal; and
- plan for and co-ordinate aftercare.
- no severe or complicated withdrawal is anticipated;
- no medical complications requiring close observation or treatment in a hospital setting are evident;
- psychiatric symptoms such as psychosis or depression are able to be safely managed in a community setting;
- has strong social supports (family members and carers require education and support themselves);
- has a drug-free, supportive and stable home environment;
- has not previously failed detoxification in the community; and
- is committed to withdrawal.
Community residential settingWhen the home environment is not supportive of detoxification or where one or more previous attempts at ambulatory or home detoxification have been unsuccessful, the person can be referred to a community residential setting for detoxification. This setting is suitable for persons who meet the criteria outlined below:
- no severe or complicated withdrawal is anticipated;
- no medical complications requiring close observation or treatment in a hospital setting are evident; and
- psychiatric symptoms such as psychosis or depression are able to be safely managed in a community residential setting.
Hospital or specialist detoxification settingThe need for admission to a hospital or a specialist detoxification unit may be less warranted than for other drug types, such as alcohol or benzodiazepines. There is also considerable variation in criteria for admission among specialist detoxification settings throughout Australia and the following criteria are intended as a guide only:
- simultaneous dependence on alcohol or other drugs that would satisfy criteria for hospital admission;
- severe dependence such that complicated withdrawal is anticipated;
- serious medical complications requiring close observation or treatment in a hospital setting are evident;
- significant psychiatric complications, specifically psychotic symptoms or severe depression and/or suicidal ideation that pose significant risk to the person or others and cannot be adequately or safely managed in a community setting;
- has an unfavourable home environment or is homeless; and
- the person has had multiple previously failed attempts at ambulatory detoxification.
Due to the high prevalence of sub-clinical and acute psychotic symptoms among regular amphetamine users (Dawe, Saunders, Kavanagh & Young, unpublished) and those presenting specifically for detoxification from amphetamines (Cruickshank & Dyer, unpublished), individuals may voluntarily or involuntarily present to mental health services for treatment in the first instance. As discussed in Chapter 2: Patterns and prevalence of psychostimulant use, there has been a six-fold increase in the numbers of Australians receiving treatment for psychosis due to psychostimulant use between 1998 and 2001 (Australian Institute of Health and Welfare, 2003b).
In the mental health setting, management of psychosis, severe depression or other disorders will occur according to standard treatment. However, to complement the usual psychiatric assessment a thorough alcohol and other drug use history should also be obtained by the mental health service and include collateral information gained from friends or relatives, which will inform the concurrent management of the psychostimulant withdrawal.
Similarly, it is essential that all AOD treatment providers undertake a thorough mental health history or mental state assessment on all psychostimulant-using clients, with a particular emphasis on psychotic symptoms and depression. For clinicians unfamiliar with such assessments, adequate training and supervision should be offered.
It is also important that services involved in the person's care collaborate to coordinate the management of individuals who require both mental health treatment and management of psychostimulant withdrawal and aftercare. Collaborative service provision may entail alcohol and other drug clinicians offering primary or secondary consultation to mental health services and vice versa and prompt assessments by either service to a person experiencing concomitant mental health and psychostimulant use problems, regardless of the initial place of presentation.