The patient is a female with substance use disorders who was admitted to an inpatient detoxification unit for 6 days. The patient presented requesting treatment of multiple substance use disorders. The patient reported she was using two bags of heroin intravenously daily for about 10 weeks. Before that the patient was using her husband's prescription opiate (Dilaudid). She was also using cannabis and cocaine regularly. The patient reported the following symptoms: yawning, hot/cold sweats, joint pain, and rhinorrhea. The initial evaluation by the nurse practitioner stated, the patient appeared "with withdrawals" but no specifics are given on physical examination. Her Clinical Opiate Withdrawal Scale (COWS) score was 12 which is consistent with mild withdrawal. The COWS was repeated and was 14 consistent with moderate withdrawal (cutoff for moderate = 13). The patient's blood alcohol level was negative. Her urine was positive for opiates, cocaine and tetrahydrocannabinol (THC). The patient denied any psychiatric symptoms including suicidal ideation. The patient was previously approved 2 days. The health plan's determination is upheld. She was not using any substances that are associated directly with the possibility of life-threatening withdrawal. She had no diagnosed psychiatric comorbidity. She had no significant physical health conditions. She reported that she had stable and safe housing with a supportive significant other who did not use drugs. There were no COWS assessments during this time period under review and no notes from physicians or nurse practitioners. There were no notes that documented the medical decision making for continued inpatient stay. Using this information and the level of care for alcohol and drug treatment referral (LOCADTR) continuation of stay instrument was used; it resulted in the finding that the patient did not meet criteria for inpatient detoxification.
1) Harwell, K & Brady, K (2018). Determining appropriate levels of care for treatment of substance use disorders. In R. Saitz (ed.), UpToDate. Retrieved on 7/7/19 from UpToDate.com 2) American Psychiatric Association (APA). Practice guideline for the treatment of patients with substance use disorders, 2nd ed. 2006. p90-100. Retrieved on 7/9/18 from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines… 3) Sevarino, K. (2019). Opioid withdrawal in adults: Clinical manifestations, course, assessment, and diagnosis. In A. Saxon (ed.), UpToDate. Retrieved on 7/7/19 from UpToDate.com 4) LOCADTR criteria.