FAQ for Community Detoxification Guidelines

General Information

Community detoxification is a treatment option that supports people to reduce or stop their use of opioids, benzodiazepines or z hypnotics through an organised process involving key workers and prescribing doctors within the community. It can be accessed as an alternative option to in-patient residential detoxification, or as a necessary step towards meeting entry requirements for residential treatment.

How do I know if community detoxification is the right treatment option for me?

Community detoxification is a treatment option for people who are taking prescribed or illicit benzodiazepines, methadone or z type drugs, who can’t or don’t want to go into a residential detoxification service. It’s also for people who want to go into residential treatment but need additional support reducing their use to meet entry criteria.

When might an individual consider community based detoxification?

They have tried residential treatment before.
To reduce their use to meet the entry requirements for residential treatment facilities.
They have child, work, college or housing commitments.
They want to get their treatment from their current key worker or GP.

Starting a community detoxification

To explore community detoxification and other treatment options you can schedule a meeting with a staff member in a service called a key worker.

A key worker is an appropriately trained staff member from a drug and alcohol project or counselling service. This person will support you through the community detoxification process.They can help you identify what triggers your use, support you through reduction and teach you relapse prevention and harm reduction skills.

Attending a key worker in a local drug and alcohol service is free of charge. Counselling prices can vary depending on the service. Some counselling services will provide low cost counselling or accept payment on a sliding scale meaning you only pay what you can afford.

How do I find a key worker?

You can access a key worker through a drug and alcohol project or counselling service. You can search drug and alcohol projects in your local area here.

My Key worker is not familar with the Community Detoxification Guidelines

You can direct your key worker to the Community Detoxification Guidelines. Services are not obliged to work as part of the Community Detox Guidelines, some services may have their own detoxification regimes in place.

Will my family GP work as part of the Community Detoxification Guidelines?

GPs are not obliged to work as part of these guidelines and may have their own regimes in place for detoxification. You can discuss the Community Detoxification Guidleines with your GP as part of your treatment options.

How can I find a local GP?

You can search GPs in your local area here.You can also discuss finding a local GP with your key worker.

What is involved in Community Detoxification?

Weekly one-to-one sessions with a key worker to receive psychosocial support. These sessions involve relapse prevention, harm reduction and interagency care plans.
A GP assessment to ensure suitability for community based detoxification.
Regular meetings with the GP, to ensure the detox is suitable and working.
6 months aftercare with a key worker in the community or in a residential treatment facility.

Do I have to be on a methadone maintenance programme to be suitable for a methadone detoxification?

People are required to be on a methadone maintenance programme and stable on a dose before starting a community detoxification. Please discuss this with your GP and key worker.

How do I know if I need a community detoxification from benzodiazepines or z drugs if my doctor prescribes them?

Community detoxification is for people who are taking prescribed or illicitly sourced benzodiazepines or z drugs and want to stop. If you want to stop using prescribed benzodiazepines you should discuss this with your GP or key worker to see if it is necessary for you to reduce your prescription. Benzodiazepines are recommended to be prescribed for 2-4 weeks.

There are circumstances in which longer-term prescription of benzodiazepines are considered appropriate because the alternative available is less beneficial. Please discuss this with your GP.

Do I need to detox or can I just stop taking my methadone, benzodiazepines or z hypnotics?

Suddenly stopping your use of methadone, benzodiazepine or z drugs can be dangerous and will leave you at risk of experiencing withdrawal symptoms, seizures or overdose if you begin using again. Withdrawal should be a gradual process and supervised by a medical professional.

What withdrawal symptoms will I experience during detox?

Withdrawal symptoms vary from person to person and depend on a number of factors such as the person’s physical and mental health, the substance they are using, the amount they are using and how long they have been using. The Community Detoxification Guidelines recommend a slow detox schedule meaning the GP reduces the doses very slowly. By doing this the person experiences less severe withdrawal symptoms then if detoxed at a fast pace.

Common methadone withdrawal symptoms:

Increased sweating
Diarrhea
Abdominal cramps
Nausea/ vomiting
Cramps/join pain
Weight change
Anxiety
Irritability
Increased cravings for opioids
Paranoid thoughts
Depression

Common benzodiazepine/ z hypnotic withdrawal symptoms:

Insomnia
Fits
Inability to stay awake
Anxiety or panic disorder
Depression
Poor memory
Poor concentration
Bowel changes
Headache
Pain and stiffness
Fatigue
Influenza like symptoms
Dizziness

Under 18s and community detoxification

People under the age of 18 are required to attend a Tier 3 service if they wish to participate in Community Detoxification. As the detoxification of adolescents can be more complex than that of adults, the appropriate treatment setting for detoxification needs to include a range of medical, psychological and social supports. Tier 3 services have specialist expertise in both adolescent mental health and addiction.

Can I do a community detoxification for other substances?

The community detox guidelines only apply to methadone, benzodiazepines and z hypnotics. Please discuss other treatment options with your key worker and GP.

For more information on other treatment please go to the Drugs.ie search directory or call the HSE Drug and Alcohol Helpline 1800 459 459.

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Key Worker Section

The choice of setting

It is the role of the GP to decide if community detoxification is a suitable option for an individual.

The GP might consider a person unsuitable for community based detoxification if they are:

medically contraindicated;
experiencing mental health issues which need to be resolved before detoxification;
currently in an unsuitable environment;
experiencing difficulties which need addressing before commencing.

Medical contraindications to Community Detoxification

Medical contraindications need to be reviewed as part of the persons suitability to engage in the community detoxification process. If a person is contraindicated as per the criteria below, that person is not automatically excluded from engaging in a community detoxification. However, suitability for detoxification is the decision of the prescribing GP.

Factors which may mean a person is not suitable for community detoxification are:

psychosis or severe mental health problems which are currently untreated;
a history of epileptic seizures while undergoing detoxification;
major medical illness;
possible dual addiction, where both addictions are unstable or where a second addiction other than opiates is uncontrolled, for example cocaine, alcohol and benzodiazepines;
pregnancy.

In the event of a person not being suitable for community based detoxification it is the role of the GP and key worker to establish an appropriate treatment setting through assessment and care planning in line with the National Drugs Rehabilitation Framework.

The key worker will need to assess the persons current situation regarding:

current drug use;
childcare commitments;
work and education commitments;
current living situation;
expectations from treatment;
previous treatment and history of withdrawals.

In line with Protocol 3 (Referral between agencies) of the National Drug Rehabilitation Framework, the key worker will need to research treatment facilities and examine:

requirements for treatment facilities;
the programmes delivered by the treatment facilities;
the length of time of the treatment;
the location of the treatment facility;
waiting lists;
any specific supports required for mental health and childcare needs.

It is acknowledged that there may be requirements and waiting lists for residential treatment. The key worker should continue the care plan and support until the service user is accepted to the appropriate facility.

How to begin a community detoxification

Firstly, a key worker should discuss providing community detoxification in their service with their line manager. The person working as part of the Community Detoxification Guidelines should be trained in relapse prevention and have a good knowledge of care planing, harm reduction and case management. It is the role of the line manager to decide if the staff memeber is appropriatly trained and has the time available to deliver community detoxification key work.

Following sign off from the line manager, the key worker should discuss the Community Detoxification Guidelines with the person accessing treatment.

The key worker forms should then be completed by the key worker and the individual before a GP appointment is arranged. Some individuals will not be comfortable discussing their drug use with their current GP and require help locating an alternative GP locally.

The individual is suitable for a community based detoxification but their current GP does not want to provode a community detoxification

The persons current GP is not obliged to provide a community detoxification. If the person is suitable for community based detoxification, an alternative GP can work with the person on their reduction. Individuals with medical cards detoxing from benzodiazepines and z hypnotics can access an alternative GP for community detoxification through a Specialist Type Consultation. This means that the person will remain with their current GP for their primary health care but attend a specialised GP in the community for their detoxification.

You can search local GPs HERE

How does a Specialist Type Consultation work?

A Specialist Type Consultation form is filled in to claim payment for a patient’s treatment by the doctor which falls outside the normal capitation payment. Payment is made by the HSE – Primary Care Reimbursement Service. You can find more information HERE

Can an alcohol detox be managed under The Community Detox Guidelines?

The Community Detoxification Guidelines do not extend to alcohol detoxification.

Can community detoxification psychosocial support be provided in a hostel?

The psychosocial components of community detoxification can be provided by any professional who is appropriately trained.

Factors which need to be considered when discussing community detoxification in hostels are:

The qualifications of the staff within the hostel
Who the person is sharing a room with – are they active drug users?
The chance of lapse or relapse in this environment
The possibility of scripts being sold for other substances
The length of time the service user will be residing in the hostel
The number of other individuals also detoxing in this service
What services are available to support the individual if they are moved from their current hostel

Why convert to diazepam for a z hypnotic detoxification?

Based on international literature, The Community Detox Guidelines make recommendations for the detoxification of z hypnotic substances through converting to diazepam. Diazepam is used in the detoxification of short acting benzodiazepines and hypnotic substances. Converting to diazepam is recommended for individuals using short acting benzodiazepines, z drugs or substances that do not easily allow for small dose reductions. Diazepam is also used for people who are likely to experience difficulty withdrawing due to a high degree of dependency.

Diazepam is a long acting benzodiazepine and therefore avoids the regular peaks and troughs in a 24 hour period that one may experience with shorter acting benzodiazepines or z drugs, which have more frequent troughs. Managing a person on diazepam is more practical for the GP and Key Worker involved because the individual craves the substance less frequently.

Converting to diazepam is the most recognized practice for z hypnotic detoxification and is supported by international literature. Despite this, it is still possible to detox a person using z type drugs. Withdrawal from z type drugs can be managed successfully in certain cases by not converting to diazepam. It is the decision of the prescribing GP if they want to conduct a like for like detoxification by using z type drugs.

Can a person get a Community Detoxification from methadone, benzodiazepines and z drugs?

If an individual is using methadone/ benzodiazepines or methadone/ z hypnotics they can access a Community Detoxification. The person will have to be stable on a dose of their methadone before they are tapered off benzodiazepines or z hypnotics. Benzodiazepines and z hypnotics must be fully detoxed before methadone reduction can begin.

Sometimes poly substance use can mask the under prescribing of methadone. The persons prescribed dose of methadone may need to be revisited once the other substances are completely detoxed.

Should the individual attend additional services?

Community detoxification should be part of an interagency care plan. The person should avail of other services depending on their needs and what services are available locally. People who attend a range of services generally have better treatment outcomes.

How long is the preparation stage before detoxification?

The preparation stage can vary depending on the individual. Some individuals find the preparation stage difficult for a number of reasons such as: the substances they use and how much they use, their living situation, their current relationship’s and support structures as well as unexpected life events.

A minimum of four key work sessions are required before detoxification begins. Some people will remain in the preparation stage for a long period of time depending on their situation and how much of the substance they are using.

The person is attending GP sessions but not the key work sessions

Psychosocial support is an essential component in the Community Detoxification Guidelines. It is vital for the individual to learn important skills about their drug use and lapses during their detox. These skills will minimalise the risk of relapse, therefore it is essential that the person attends their psychosocial support sessions with their key worker. If the person is not attending the recommended sessions during detoxification the GP should be contacted.

Do I need to collect data on community detoxification?

There is no requirement as part of the Community Detox Guidelines to collect data on the initiative. Each service can record community detoxes through the National Treatment Reporting System.

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General Practitioner (GP) Section

What is involved in a community detox?

Weekly one-to-one sessions with a key worker to receive psychosocial support. These sessions involve relapse prevention, harm reduction and interagency care plans.
A GP assessment to ensure the person is suitable for community based detoxification.
Regular meetings with the GP, to ensure the detox is suitable and working.
6 months aftercare with a key worker in the community or in a residential treatment facility.

What is psychosocial support?

‘Psychosocial interventions are structured psychological or social interventions used to address substance-related problems. They can be used at different stages of drug treatment to identify the problem, treat it and assist with social reintegration’ (EMCDDA, 2015).
Psychosocial support as part of community detoxification will be provided by a key worker and include harm reduction, relapse prevention and interagency care planning. The key worker will help the service user understand what triggers their drug use and support them in reducing their use to minimalise the risk of relapse and overdose.

Who is a key worker?

A key worker is a named person who is assigned to work closely with the individual and provide a range of psycho-social interventions and advocacy. A key worker can be employed in specialist projects or in mainstream health services. Some people may have an existing key worker from a drug, homeless or mental health service that they want to get their detox support from.

How do I find a key worker for my patient?

Firstly ask your patient if they attend any support services or if they have a key worker or counsellor. If they do, this service or professional can be contacted to discuss community detoxification.

If the individual does not currently attend any services or professionals for psychosocial support you will have to discuss what type of service the patient would like to attend for their detox support work. You can find a list of local drug and alcohol services here.

Can I provide a benzodiazepine/ Z detoxification for a medical card patient that is attending a different GP?

Patients with medical cards using benzodiazepines/z drugs can access an alternative GP for a Specialist Type Consultation. This means that the service user remains with their current GP for their primary health care but will attend a specialised GP in the community for their detoxification.

How does a Specialist Type Consultation work?

I would like further information on methdone, benzodiazepines and z hypnotics

Benzodiazepines: Good Practice Guidelines for Clinicians: LINK

The Report of The Benzodiazepine Committee: LINK

The Ashton Manual: LINK

The Introduction of the Opioid Treatment Protocol: Link