outpatient detox

[sweetlenovo88]

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What are your thoughts doing this on the side for opiate and mild/moderate benzo/etoh. Detox over a couple of weeks or 1-2 months with suboxone or librium for etoh. I have a friend doing this and they bill insurance and/or cash and it's lucrative. They refuse to do severe abuse cases. Biggest concern is liability and patients not following protocols and continuing to abuse. Benefit to patient is privacy and being able to continue working during the process. Their site is outpatientdetox.com. Thoughts?

 

[sloop]

Obviously I'm still a medical student so standard disclaimer of "I know my opinion means almost nothing; I'm probably wrong about a lot of this; I've never actually known what it's like to have attending level responsibility for patients, etc."

That being said, knowing what little I know now, my opinion is probably:

Opiates: Whatever. If a patient wanted it and was motivated, it doesn't really matter to me. They can go feel like **** for a week in whatever setting they prefer. It's not going to kill anyone.

Benzos/Alcohol: I would be extremely uncomfortable referring anyone with signs of physical dependence to be detoxed on an outpatient basis, even if mild. I would feel terrible about myself if I said to someone "yeah, your withdrawal is mild so outpatient detox would probably be okay" only to come to find out that they had some unrecognized predisposition and went home to seize in their couch.

 

[strangeglove]

What do you mean by "on the side?" If you do this, it should be a treatment just like any other you provide.

 

[splik]

It's quite common for alcohol withdrawal to be managed in the outpatient setting. We've been doing this for years. I learned about outpatient management of withdrawal as a med student and that was 10 years ago and many papers from the 1990s discuss this. For mild or moderate alcohol use with no history of withdrawal seizures, DTs, and social support it is perfectly reasonably. Many of these patients would not be eligible for inpatient detox anyway. Patients are frequently sent from from ERs with librium or valium to detox, knowing full well they will just drink if necessary. Gabapentin and depakote are also used in conjunction with benzos or sometimes alone. At our VA, patients are routinely discharged from the ER with a prescription for gabapentin 400mg TID for outpatient management of alcohol withdrawal with addictions follow up. The important thing is they have close follow up and are receiving appropriate support and treatment.

Benzo withdrawal is typically managed on an outpatient basis. Many detox facilities will flat out refuse to take patients on benzos, particularly the public ones. It takes weeks, and often months-years to get people of benzos.

I would not be concerned about liability issues, for many patients this is the standard of care. You just need to make sure that patients are appropriate, have close management, social support, and are aware of the risks and when to call or go to the ER etc.

 

[HarryMTieboutMD]

Yeah, ignore what the medical student wrote (which should be a standing rule because med students don't know anything) and listen to what Splik said. Here are some of my preferences:

EtOH- main thing is going to be history (amount, hx seizures/DTs, which ideally needs to be verified by collateral) and social support (ie, can someone reliably give the patient his or her benzos). I'm not a huge fan of adjunctive/non benzo treatment, but gabapentin can be good as a maintenance medication as well. And why is your colleague doing a several week/month taper for EtOH withdrawal? You can safely taper someone off in a few days.
Benzos- for really bad cases (again based on history) you can admit briefly just for safety but ultimately they should be transitioned to librium or klonopin (because blood levels remain steady) and tapered off over several weeks as an outpatient. Most cases of pure benzo tapering can be done as an outpatient, as Splik mentioned.
Opioids- Opioid withdrawal is not an inpatient issue UNLESS its precipitated (when COWS isn't done correctly and Buprenorphine induction is started prematurely... or the patient decides to take Revia after shooting up heroin- saw this twice in a month as an intern). Again, why is your friend doing a slow week/month long taper if he/she just plans to detox the patient anyway? The literature from high impact journals specifically shows that this is NOT effective and leads to relapse. If the patient is not a candidate for maintenance treatment or you are in a setting where you can only detox, this can be done over 5 days using bup+symptomatic treatment.

In any case, treating withdrawal is the easy part... I would be hesitant to take a patient with a severe substance problem off of any maintenance medication (after rehab) unless he or she demonstrates enthusiasm for going to meetings/sponsor/12 Steps or some other continued support system with focus on sobriety. Obv the 12 Steps are the most established and thus it's easier to ascertain level of engagement, enthusiasm, commitment to recovery than some of the other things people do.

 

[birchswing]

What are your thoughts doing this on the side for opiate and mild/moderate benzo/etoh. Detox over a couple of weeks or 1-2 months with suboxone or librium for etoh. I have a friend doing this and they bill insurance and/or cash and it's lucrative. They refuse to do severe abuse cases. Biggest concern is liability and patients not following protocols and continuing to abuse. Benefit to patient is privacy and being able to continue working during the process. Their site is outpatientdetox.com. Thoughts?

I looked over the site and can speak to the benzo withdrawal part.

What they are offering actually sounds far superior to what you would get from a regular outpatient practice for the purpose of benzo withdrawal. They meet with the patient twice a week and say they taper over 90 days. You can't get that type of attention from most doctors in normal outpatient practice, and at the same time most inpatient "detox" (I don't like that word) facilities are not set up for benzo withdrawal. In my experience in having called such facilities, the methods are as varied as using a phenobarbital substitution to using a low-dose flumazenil IV drip. They're all over the map in methodology, and they generally don't keep patients long enough IMO or use what I think is the healthiest approach (a slow taper). Given the more typical outpatient experience of seeing a psychiatrist every 2-3 months, seeing someone twice a week during benzo withdrawal sounds extraordinarily appealing in terms of both getting reassurance and having someone monitor physiologic symptoms and personally would be of huge interest to me if it were available in my area.

PS: I never would have trusted this was a legitimate site unless I saw a physician posting it. The web-site name and look is rather generic. I sometimes am wary of the word "detox" as it's often associated with pseudo-science, but this place does seem more legitimate than its name and look imply.

PSS: A facility like this, even if it only focused on benzo dependence, I think would have a full business in my region.