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In this stage the client and nurse identify and pursue goals. It is important that the goals are realistic. Achieving small goals can encourage the client and help to produce a sense of self-efficacy. Not achieving can create a sense of failure and trigger a return to precontemplation or contemplation stages. A solution-focused approach can be beneficial as it avoids emphasizing problems, seeks to enhance the client’s sense of their own competence and ensures that he or she receives positive feedback.

Many people will decide to stop using substances altogether and some are able to gradually decrease use themselves. Others, however, will need pharmacological interventions to enable them to detoxify safely. Some people will detoxify in the community but others will require inpatient admission. Factors influencing this decision include: the number and quantity of substances being used, previous withdrawal experiences, physical and mental health, availability of support in the community, family responsibilities (for example, childcare), and personal preference. Maintaining the client’s safety is essential. People who are using dangerous combinations of substances, have experienced withdrawal seizures, delirium tremens or whose physical health is very poor must be admitted to hospital. For people whose mental health tends to be unstable this may also be the best option, and once detoxified, time in an inpatient setting can allow a more thorough mental state assessment to be made. Detoxification from opiates is usually undertaken by prescribing methadone linctus. An initial dose comparable to the quantity of illicit heroin (or other substance) being used is identified. The rate of reduction will vary from person to person. For community treatment it is recommended that methadone consumption is supervised by a professional for at least three months.

Continued supervision may be desirable for people whose mental health is unstable. Newer drugs which are being used in the detoxification of opiate users are buprenorphine (an opioid) and lofexidine (not an opioid but effective in the management of withdrawal symptoms). Benzodiazepine detoxification is achieved by prescribing diazepam, a long-acting benzodiazepine, at an equivalent dose to the drug which was being taken and then reducing the dose. The reduction rate can be more rapid at the beginning, but clients are often extremely anxious about detoxification. A slow gradual reduction, which the client feels is achievable, is preferable to a more rapid one which makes the client overly anxious and may result in them obtaining illicit supplies. Alcohol detoxification is achieved by prescribing a reducing regimen of a long-acting benzodiazepine (diazepam or chlordiazepoxide) over a period of about a week. Close monitoring of the client is required because of the risks if he or she drinks alcohol while taking benzodiazepines, and because of the severe complications that can be associated with withdrawal (for example, seizures). People using stimulants, cannabis or ecstasy do not need pharmacological interventions to stop using. However, anti-depressants can be useful for people who have been using crack and cocaine, as low mood can persist for many weeks. Clients may need high levels of support during detoxification, and those completing detoxification in inpatient settings are likely to feel well supported, with staff on hand and peer encouragement.

For those detoxifying in the community the process may be more difficult. As well as making use of facilities accessible through substance misuse services (for example, supportive counselling and complementary therapies such as auricular acupuncture and shiatzu massage) enlisting the support of family and/or friends can be important. Detoxification should not be seen in isolation. Coming off drugs is said to be the easy part, it is staying off that is more difficult. This will not be achieved unless the client has acquired new skills and made lifestyle changes. Work on these areas may run in parallel with the detoxification process and will certainly need to continue after.

Tags: substance abuse, treatment