From SAMHSA’s accreditation guidelines for OTPs:
Voluntary medically supervised withdrawal is completely different from involuntary tapering, administrative withdrawal, or other types of medically supervised withdrawal. The physician initiates voluntary medically supervised withdrawal from medication-assisted treatment in collaboration with and at the request of the rehabilitated patient. In initiating voluntary medically supervised withdrawal, the physician reduces dosages of medication at a rate well tolerated by the patient and in accordance with sound clinical judgment and close observation of the patient. Please refer to TIP 43 for guidance (http://www.ncbi.nlm.nih.gov/books/NBK64164/pdf/TOC.pdf).
For women with childbearing potential, the physician conducts an assessment for pregnancy and reviews the results of a pregnancy test before initiating medically supervised withdrawal. For pregnant patients, the physician should not initiate withdrawal before 14 weeks or after 32 weeks of gestation. When the patient experiences intolerable withdrawal symptoms or actual or potential relapse, the physician should consider halting the withdrawal process and possibly restoring the patient to a previously effective dose. Patient and physician together may decide that an additional period of maintenance is necessary before further medically supervised withdrawal is attempted. Regardless of whether medically supervised withdrawal is conducted with or against medical advice, very careful review of the risks and benefits of withdrawal from maintenance therapy must be provided and thorough informed consent obtained from patients choosing medically supervised withdrawal. Because of the risk of fatal overdose if relapse occurs, medically supervised withdrawal services should be accompanied by relapse prevention counseling, overdose prevention education and naloxone prescription. The treatment and aftercare plans should always include a strategy to transition to medication-assisted treatment with antagonist or agonist therapy if needed. OTPs should offer a variety of supportive options as part of the transition from opioid agonist therapy. For example increased counseling should be available prior to discharge, and participants encouraged to attend a 12-step or other mutual-help program sensitive to the needs of patients receiving medication-assisted treatment.
Involuntary “administrative withdrawal” requires OTPs to define and follow due process. The underlying goal is for involuntary medically supervised withdrawal to reflect a humane partnership between the patient and the treatment program. The program policies and procedures must take into consideration, on a case-by-case basis, all factors affecting the patient and all the steps involved in the process must be documented. Because of the risk of fatal overdose if relapse occurs, medically supervised withdrawal services should be accompanied by relapse prevention counseling, overdose prevention education as well as a naloxone prescription. The treatment and aftercare plans should always include a strategy to transition to medication assisted treatment including antagonist pharmacotherapy if needed. 42 CFR § 8.12 does not specify under what conditions administrative withdrawal is considered appropriate. Standard practice regarding involuntary discharge among OTPs provide for the following situations: Nonpayment of fees. Remedies may include referral to a more affordable OTP or other forms of medication-assisted treatment.
When a patient is administratively discharged from an OTP, the program must employ the same principles as those used for voluntary medically supervised withdrawal from medication. The goal is to follow a withdrawal schedule that is based on sound clinical judgment and close patient monitoring. A schedule for medically supervised withdrawal for administrative withdrawal from treatment is generally a minimum of 21 days, but the physician may adjust this timeframe depending on clinical factors. The patient’s condition during this medically supervised withdrawal and all steps to address it should be documented in the patient’s record.
Access TIP 43 (http://www.ncbi.nlm.nih.gov/books/NBK64164/pdf/TOC.pdf) for additional information.
