Guidelines For Managing Substance Withdrawal in Jails

U.S.
Department of Justice
Office of Justice Programs
Bureau of Justice Assistance
GUIDELINES FOR
MANAGING SUBSTANCE
WITHDRAWAL IN JAILS
A Tool for Local Government Officials, Jail Administrators,
Correctional Officers, and Health Care Professionals
June 2023
U.S. Department of Justice
810 Seventh Street NW
Washington, DC 20531
Amy L. Solomon
Assistant Attorney General
Karhlton F. Moore
Director, Bureau of Justice Assistance
Alix M. McLearen
Acting Director, National Institute of Corrections

Building Solutions | Supporting Communities | Advancing Justice
www.ojp.gov
Bureau of Justice Assistance

bja.ojp.gov
June 2023
NCJ 306491
Photo Credit: iStock.com/ljubaphoto
This project was supported by Grant No. 2019-AR-BX-K061 awarded by the Bureau of
Justice Assistance. The Bureau of Justice Assistance is a component of the Department of
Justice's Office of Justice Programs, which also includes the Bureau of Justice Statistics,
the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention,
the Office for Victims of Crime, and the SMART Office. Points of view or opinions in this
document are those of the authors and do not necessarily represent the official position or
policies of the U.S. Department of Justice.
Endorsing Organizations
The following organizations and their boards of directors endorse the Guidelines for Managing Substance Withdrawal
in Jails: A Tool for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals
published by the U.S. Department of Justice’s Bureau of Justice Assistance (BJA) and National Institute of Corrections (NIC).
American Correctional Association (ACA)
American Society of Addiction Medicine (ASAM)
American Jail Association (AJA)
Major County Sheriffs of America (MCSA)
National Association of Counties (NACo)
National Commission on Correctional Health Care (NCCHC)
National Sheriffs’ Association (NSA) [but not the NSA Board of Directors]
Small & Rural Law Enforcement Executives Association (SRLEEA)
Guidelines for Managing Substance Withdrawal in Jails i

Foreword
Death and suffering due to withdrawal from opioids, alcohol, and other substances are preventable. Local government
officials, jail administrators, correctional officers, and health care professionals have an opportunity to save lives and
promote the wellbeing of individuals in jail, an opportunity bound by legal obligations set forth in the Americans with
Disabilities Act and various federal civil rights acts.
To help jails and communities establish or enhance policies and procedures that appropriately address withdrawal, as
well as support custody and health care staff in carrying out their responsibilities, the Bureau of Justice Assistance (BJA)
and the National Institute of Corrections (NIC) are excited to present Guidelines for Managing Substance Withdrawal
in Jails: A Tool for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals.
This groundbreaking document not only responds to urgent requests for guidance from the field but also advances
the National Drug Control Strategy of improving access to medication for opioid use disorder for populations who are
incarcerated or reentering the community.1
We understand that jails have a wide range of medical capabilities and encourage each facility to explore options
for implementing the guidelines within their systems and communities. This will involve collaboration between jail
administrators and their providers to establish policies and procedures for custody staff and health care professionals.
Implementation of the guidelines also calls for collaboration within the community: namely, assessment, planning, and
coordination with hospitals, local emergency medical services, opioid treatment providers, county partners, and other
entities. BJA and NIC will support implementation efforts of jails and their partners through BJA’s Comprehensive
Opioid, Stimulant, and Substance Use Program (COSSUP) Jail Resources, offering a variety of training and technical
assistance opportunities, including resources, peer-to-peer learning, and communities of practice.
We profoundly appreciate the time and commitment of the jail administrators, clinicians working in criminal justice
settings, and substance use disorder specialists who wholeheartedly shared their expertise, experience, and energy
with us to create these guidelines. Many of these experts are now poised to help jails and their partners implement the
guidelines through training and technical assistance offered through BJA’s COSSUP Jail Resources.
Thank you is also extended to the dozens of field reviewers from federal agencies and national associations who
provided critical feedback on the draft document, as well as staff members from Advocates for Human Potential, Inc., the
American Society of Addiction Medicine, and the National Commission on Correctional Health Care, who collaboratively
led the many facets of writing and managing this effort.
Together, we can expand access to high-quality and continuous care, thereby preventing deaths from withdrawal and
overdose and paving the way toward long-term recovery.
Karhlton F. Moore
Director, Bureau of Justice Assistance
Alix McLearen
Acting Director, National Institute of Corrections
Acknowledgements
Guidelines for Managing Substance Withdrawal in Jails is the product of the vision, expertise, and perseverance of many
people. The following individuals are acknowledged for their extensive contributions:
Federal Champions Technical Support Team Members Other federal partners who
• Stephen Amos, National Institute Advocates for Human Potential, Inc. contributed to this work include:
of Corrections, U.S. Department • Linda Frazier, M.A., RN, MCHES • Federal Bureau of Prisons
of Justice
• Kay S. Peavey, B.A. • National Institute on Drug Abuse
• Margaret Chapman, Bureau
• Pam Rainer, M.S.W. • Substance Abuse and Mental
of Justice Assistance, U.S. Health Services Administration
Department of Justice • Deann Rogers, M.S.
• U.S. Department of Justice, Civil
• Ruby Qazilbash, Bureau of Justice American Society of Addiction Rights Division
Assistance, U.S. Department of Medicine
Justice • U.S. Department of Justice,
• Maureen Boyle, Ph.D.
Office of Community Oriented
Expert Committee Members • Taleen Safarian, B.A. Policing Services
• Jeffrey Alvarez, M.D., CCHP National Commission on Correctional • U.S. Department of
• Andrew F. Angelino, M.D. Health Care Veterans Affairs
• Oscar Aviles, CPM, CJM, • Brent Gibson, M.D., M.P.H.,
CCE, CCHP CCHP-P
• Chief Deputy Jeff Clark, M.J.A. • Wendy Habert, M.B.A., PHR,

CCHP
• Kevin A. Fiscella, M.D.,
M.P.H., CCHP • Laura Lutgen-Nieves, Ph.D.
• Carrie Hill, Esq. • Jim Martin, M.P.S.A., CCHP

• Miriam S. Komaromy, M.D. • Deborah Ross, CCHP
• Shannon Robinson, M.D. • Jaime Shimkus, CCHP
• Sandra Springer, M.D. • Kim Sterling, M.B.A.
• Marc F. Stern, M.D., M.P.H. • Claire Wolfe, M.A., M.P.H., CCHP
• Chief Deputy Geoff Stobart

• Donna Strugar-Fritsch, B.S.N.,
M.P.A., CCHP
Guidelines for Managing Substance Withdrawal in Jails v

Table of Contents
Introduction................................................................................................................................................................. 1
Purpose ...............................................................................................................................................................................1
Background..........................................................................................................................................................................2
Development of the Guidelines...........................................................................................................................................2
Content Overview................................................................................................................................................................3
The Withdrawal Management Process......................................................................................................................... 5
Screening.............................................................................................................................................................................5
Clinical Assessment..............................................................................................................................................................5
Onsite Withdrawal Management Versus External Transfer.................................................................................................6
Pathway to Recovery............................................................................................................................................................6
General Guidance........................................................................................................................................................ 7
Screening To Flag Withdrawal Risk......................................................................................................................................7
Monitoring for Withdrawal Signs and Symptoms................................................................................................................9
Clinical Assessment and Diagnosis....................................................................................................................................11
Level of Care......................................................................................................................................................................13
Withdrawal Management by Qualified Health Care Professionals....................................................................................14
Monitoring Patients During Withdrawal Management......................................................................................................15
Medications........................................................................................................................................................................16
Staffing and Staff Training..................................................................................................................................................17
Quality Assurance..............................................................................................................................................................18
Supportive Care.................................................................................................................................................................18
Guidelines for Managing Substance Withdrawal in Jails vii

Reentry...............................................................................................................................................................................19
Suicide................................................................................................................................................................................21
Pregnancy and Postpartum................................................................................................................................................21
Older Adults.......................................................................................................................................................................22
Alcohol Withdrawal.................................................................................................................................................... 25
Screening...........................................................................................................................................................................25
Monitoring for Withdrawal Signs and Symptoms..............................................................................................................26
Withdrawal Management by Qualified Health Care Professionals....................................................................................27
Level of Care......................................................................................................................................................................28
Medications........................................................................................................................................................................29
Supportive Care.................................................................................................................................................................31
Managing Comorbidities...................................................................................................................................................32
Polysubstance Use Disorder..............................................................................................................................................33
Sedative Withdrawal.................................................................................................................................................. 35
Screening...........................................................................................................................................................................35
Level of Care......................................................................................................................................................................37
Medications........................................................................................................................................................................38
Recommendations.............................................................................................................................................................38
Supportive Care.................................................................................................................................................................39
viii BUREAU OF JUSTICE ASSISTANCE

Opioid Withdrawal..................................................................................................................................................... 41
Screening...........................................................................................................................................................................41
Medications........................................................................................................................................................................43
Level of Care......................................................................................................................................................................50
Supportive Care.................................................................................................................................................................51
Reentry...............................................................................................................................................................................53
Stimulant Withdrawal................................................................................................................................................ 55
Screening...........................................................................................................................................................................56
Medications........................................................................................................................................................................57
Level of Care......................................................................................................................................................................59
Supportive Care.................................................................................................................................................................59
Appendixes................................................................................................................................................................ 61
Appendix A: Development Team............................................................................................................................... 63
Expert Committee ............................................................................................................................................................63
Federal Project Champions................................................................................................................................................64
Technical Support Team.....................................................................................................................................................64
Appendix B: Full Methodology.................................................................................................................................. 67
Overview of Approach ......................................................................................................................................................67
Guidelines for Managing Substance Withdrawal in Jails ix

Task 1: Literature Review...................................................................................................................................................68
Task 2: Identification of Draft Statements and Appropriateness/Feasibility Rating .........................................................70
Appendix C: Preferred Terminology.......................................................................................................................... 73
Appendix D: ASAM’s Principles of Drug Testing During Withdrawal Management................................................... 75
Appendix E: Monitoring Patients During Withdrawal Management.......................................................................... 77
Appendix F: Withdrawal Pharmacotherapy............................................................................................................... 79
Appendix G: Indicators of Dehydration..................................................................................................................... 81
Appendix H: Expert Committee Members’ Current Industry Relationships............................................................... 83
Appendix I: Field Reviewers...................................................................................................................................... 85
Appendix J: Field Reviewers’ Current Industry Relationships.................................................................................... 89
Appendix K: Glossary................................................................................................................................................ 91
Appendix L: Acronym Glossary.................................................................................................................................. 97
Appendix M: Resources............................................................................................................................................. 99
Clinical Practice Studies.....................................................................................................................................................99
Legislation, Rules, and Regulations...................................................................................................................................99
Pregnancy and Postpartum..............................................................................................................................................100
Substances.......................................................................................................................................................................100
Treatment and Medication...............................................................................................................................................101
Reentry.............................................................................................................................................................................102
Screening and Assessment..............................................................................................................................................103
Telehealth.........................................................................................................................................................................104
Endnotes.................................................................................................................................................................. 105
x BUREAU OF JUSTICE ASSISTANCE

Introduction
Purpose
Guidelines for Managing Substance Withdrawal in Jails: A Tool for Local Government Officials, Jail Administrators,
Correctional Officers, and Health Care Professionals is designed to support jails (including detention, holding, and
lockup facilities) and communities in providing effective health care for adults (18 years of age and older) who are
sentenced or awaiting sentencing to jail, awaiting court action on a current charge, or being held in custody for other
reasons (e.g., violation of terms of probation or parole) and are at risk for or experiencing substance withdrawal. These
guidelines will help jail administrators, custody staff, jail-based health care professionals, local government officials, and
community providers:
• Unite around a shared understanding of appropriate policies and procedures for responding to individuals at risk for
or experiencing withdrawal.
• Understand standards of care for:
o Managing withdrawal from alcohol, sedative-hypnotics (hereafter referred to as “sedatives” for simplicity),
and stimulants.
o Avoiding or minimizing opioid withdrawal through effective opioid use disorder (OUD) treatment.
• Determine the level of clinical severity that can be managed with the jail’s available medical resources, setting
thresholds for when individuals need to be transferred to a higher level of care at an external medical facility.
Smaller jails, or jails with fewer internal resources, are expected to meet the same standards of care as larger, better-
resourced jails, but how they achieve this will differ. For example, it is expected that shortly after arrival at a jail, all
individuals are screened for their risk of substance withdrawal. A well-resourced jail may fulfill this expectation using
nurses to screen. A less well-resourced jail may fulfill the expectation by using custody staff who are well-trained and
supervised (as defined in the glossary and detailed in Staffing and Staff Training) or through telehealth (see Screening
To Flag Withdrawal Risk). The guidance offered herein is intended for all jails, with specific suggestions for jails with
fewer resources.
The extent of custody staff training and technical assistance needed to implement these guidelines will vary by jail. Jail
Resources, housed on BJA’s Comprehensive Opioid, Stimulant, and Substance Use Program (COSSUP) website, supports
jails’ efforts to connect individuals to evidence-based withdrawal and substance use disorder (SUD) services and facilitate
continuity of care upon community reentry. More specifically, these webpages house comprehensive information on
these guidelines, offering resources, tools, online learning (e.g., webinars, courses, videos), and technical assistance to
support jails’ implementation of these recommendations.
Guidelines for Managing Substance Withdrawal in Jails 1

Background
Sixty-three percent of individuals sentenced to jail (compared to 5 percent of adults in the general population) meet
diagnostic criteria for SUD.2 The typical short stays in jail, combined with scant resources for supportive services, present
challenges for addressing substance withdrawal and SUD, yet jurisdictions are responsible for the health and well-being
of those in custody.
Acute substance withdrawal, left unaddressed, can result in serious health complications and death. The prevalence of
such deaths is difficult to determine because they often have been categorized as “illness” or “other” (e.g., aspiration
pneumonia due to severe vomiting, profound dehydration) due to lack of a specific reporting category for deaths
associated with drug or alcohol withdrawal.3
Suicide is the leading single cause of death in jails,4 but the exact role of substance withdrawal in these deaths is difficult to quantify.5 Risk for
suicidal ideation and attempts is increased among individuals in substance withdrawal and those with an SUD. Notably, individuals with OUD
have a threefold higher risk for suicidal behavior than those without OUD.6
Wrongful death lawsuits and other litigation for inadequate medical care are resulting in large financial settlements or
judgments against counties, jail administrators, staff, and health care providers. Managing Substance Withdrawal in
Jails: A Legal Brief provides an overview of key legislation and significant court cases related to substance withdrawal, as
well as steps for jails and communities seeking to create a comprehensive response to SUD.
Beyond complying with the law, effectively managing withdrawal and SUD has significant potential for individual and
societal benefits. For example, patients who received methadone treatment from a community provider prior to entering
jail and continued to receive methadone from the same community provider while in jail “were less likely to receive
disciplinary tickets while incarcerated and more likely to re-engage in community-based [methadone treatment] after
release compared to those who underwent forced withdrawal from methadone.”7 Long-term pharmacotherapy for OUD
mitigates opioid withdrawal syndrome and minimizes the risk of opioid overdose death, which is significant during the
weeks following release from incarceration due to reduced tolerance.
Opioid Withdrawal Considerations

Effective management of opioid withdrawal involves initiation of long-term buprenorphine or methadone. When administered in a timely manner,
these medications prevent withdrawal and treat OUD. (Naltrexone, another U.S. Food and Drug Administration-approved [FDA] medication for
OUD, is not approved for withdrawal management purposes, does not relieve withdrawal symptoms, and may precipitate withdrawal.)
Opioid withdrawal management without ongoing pharmacotherapy does not treat the underlying OUD and leaves the patient at risk for
overdose and death.
Development of the Guidelines

Responding to the urgent need for recognition and appropriate management of substance withdrawal, the Bureau of
Justice Assistance (BJA), in partnership with the National Institute of Corrections (NIC), formed a collaboration with
Advocates for Human Potential, Inc. (AHP), the American Society for Addiction Medicine (ASAM), and the National
Commission on Correctional Health Care (NCCHC) to develop guidelines informed by evidence-based medical practice,
while accounting for the practical realities of jails and community providers. Collectively, they facilitated the work of
an expert committee (EC) to develop these guidelines. Members of the EC included eight clinical experts (including
addiction specialists) with experience in criminal justice settings and four experts in jail administration. Appendix A lists
members of the EC, as well as the technical support team who carried out the development methodology.
2 BUREAU OF JUSTICE ASSISTANCE

These guidelines were developed using a modified RAND/UCLA Appropriateness Method (RAM). RAM is a systematic
approach encompassing review of existing literature, clinical guidelines, and standards; appropriateness ratings;
stakeholder comment and reconciliation; and document development.8 The process combines scientific evidence and
clinical knowledge to determine the appropriateness of a set of clinical procedures. The modified RAM used for the
development of these guidelines combined the best available scientific evidence with the collective judgment of clinical
and jail administration experts weighing both clinical best practices and feasibility in jail settings. (For a full description of
the methodology, go to appendix B.)
Content Overview
Following a brief description of the withdrawal management process, the recommendation statements crafted by the
EC and supporting narrative are presented in five sections. General Guidance addresses issues that are universal to
withdrawal management in jails; the ensuing sections focus on substance-specific considerations for alcohol, sedatives,
opioids, and stimulants.a
The numbered recommendation statements in each section provide guidance for establishing policies and procedures
related to withdrawal management. Some recommendations are included to help clinicians make decisions about
services and levels of care for individuals at risk for or experiencing withdrawal. Other recommendations are intended to
ground jail administrators, and to some degree health directors, in the basics of withdrawal management to:
• Facilitate effective management of jail resources and foster community partnerships.
• Inform scope-of-work requirements when creating requests for contract proposals and in writing the resulting
contracts in jails that outsource health care services.
It is the jurisdiction’s responsibility to determine how best to apply these recommendations (e.g., whether additional staff
or contracts are needed, updating policies and procedures). Recommendations in this document do not supersede any
federal, state, local, or tribal regulations.
A Note on Terminology
Using clinically correct and non-stigmatizing language promotes understanding of SUD as a complex medical condition.
“Withdrawal management” is used in this document to describe services to assist a patient’s withdrawal from substances,
a process involving far more than removing substances from the body (commonly referred to as “detoxification” or
“detox”). The authors have made every effort to incorporate appropriate terminology and encourage readers to
use and promote the use of person-first and non-stigmatizing language. (For more information, go to appendix C.)
Clinical staff are purposely identified throughout this document (e.g., “physician” is used only when a physician is
required), with the expectation that clinical staff meet and adhere to the requirements of their position, as well as operate
within their scopes of practice. Clinical staff referred to in this document include physician, prescriber, provider, qualified
health care professional, qualified health care staff, qualified mental health care professional, and responsible provider.
Likewise, the terms “individual” and “patient” are used intentionally: “individual” refers to a person who is not currently
being treated for substance withdrawal or SUD, whereas “patient” refers to a person whose substance withdrawal or
SUD is being treated. All terms defined in the glossary are hyperlinked to their definition at first use.
a
Nicotine withdrawal may exacerbate other withdrawal symptoms but is beyond the purview of this document. NCCHC standards include availability of
nicotine replacement products when ordered by a physician.

The Withdrawal
Management Process
Regular and active observation by custody and health care staff is the foundation for an effective withdrawal
management process, which begins upon an individual’s arrival to the jail. Diligent observation and structured
screening help identify individuals who may be at risk for substance withdrawal.
Individuals who appear unwell are referred for immediate clinical assessment conducted by a qualified health care
professional. Broadly defined, “appears unwell” encompasses observed signs and symptoms obvious to a layperson that:
• An individual may be sick (physically or psychologically), which includes signs of or self-reported intoxication
or substance withdrawal. Symptoms of the latter may present at any time (including upon arrival to the facility);
typically, they emerge within 72 hours of arrival.
• The condition of a patient who has already been assessed by a qualified health care professional is worsening,
becoming unstable, or becoming a danger to the patient or others.
Screening
All individuals, regardless of their length of stay in jail, should be screened for risk of withdrawal. Screening
is critical to fully understanding and meeting the often acute and complex substance withdrawal-related needs of
individuals entering jail. Screening will help identify individuals in need of immediate clinical assessment, including
anyone who:
• Reports or is known to have used alcohol or sedatives recently, regularly, and heavily.
• Reports using alcohol or sedatives in the past week and also reports a history of complicated withdrawal.
• Is known to be pregnant and screens positive for alcohol or opioid use.
Otherwise, individuals who screen positive for withdrawal risk and who appear well are monitored by health care staff or
well-trained custody staff and referred for immediate clinical assessment upon emergence of withdrawal signs or symptoms.
Clinical Assessment
A major goal of the initial clinical assessment in a jail setting is to address the need for swift action to avoid critical
biomedical or psychiatric issues related to intoxication or withdrawal (e.g., acute withdrawal syndromes, overdose,
suicidality, and other acute psychiatric symptoms). Findings of the clinical assessment inform whether the patient’s needs
can be addressed at the jail or require transfer to a higher level of care.

Onsite Withdrawal Management Versus External Transfer
When onsite withdrawal management is appropriate, the treating clinician provides specific guidance regarding ongoing
monitoring and care of the patient during withdrawal management. Prescribers may call upon qualified health care
staff (or custody staff who are well-trained for the task) to monitor vital signs and assess withdrawal symptoms using
structured, objective scales.
Jails have highly variable levels of health care capacity. A qualified health care professional should determine whether the
jail has the capacity to safely and effectively manage the anticipated withdrawal syndrome. If not, the patient should be
transferred to a higher level of care.
Pathway to Recovery
Ideally, identifying and managing substance withdrawal among individuals who are detained is a component of a more
far-reaching approach to helping individuals engage in ongoing SUD treatment and recovery. This approach requires
coordination with the greater community to:
• Enable patients who are taking buprenorphine or methadone to treat OUD to continue upon entry to jail.
• Help small, rural, and under-resourced jails explore community partnerships to overcome challenges in providing
withdrawal management services (e.g., lack of health care professionals on staff, lack of secure medication storage, etc.).
• Educate patients about community resources, including where to access continuing withdrawal management and
SUD care in the community.
• Support effective reentry planning (when feasible), including coordinated referrals to ongoing care for SUD.

General Guidance
Screening To Flag Withdrawal Risk

Individuals who consume alcohol or other drugs may experience withdrawal when they abruptly stop or reduce
consumption, with several factors, such as the duration of heavy and regular use, prior episodes of withdrawal, and
presence of other medical conditions, influencing the likelihood and severity of withdrawal. Screening is critical for
identifying those at risk for withdrawal, allowing custody and health care staff to take appropriate steps to intervene.
A number of brief, standardized screening tools are available to identify recent, regular, or heavy substance use. These
tools do not assess signs and symptoms of withdrawal syndromes but can help gauge risk for withdrawal and identify
individuals who should be monitored for the emergence of withdrawal signs and symptoms as well as those who
should be referred for immediate clinical assessment. Screening usually includes documenting type(s) of substances
used; route(s) of use (oral, injection, snorting); amount of substance used; frequency and recency of use; and history of
complicated withdrawal.
Confidentiality
Accurate information regarding recent substance use is critical for safe management of the individual’s health. However, individuals may be
reluctant to share information regarding substance use with custody officers. Staff who conduct screenings for withdrawal risk should be well-
trained to inform individuals of confidentiality protections before the screening process begins.
Each jurisdiction may be subject to different laws and regulations governing the confidentiality of health information, which should be
considered when the jail develops their policies and procedures regarding the confidentiality and sharing of health information. It is helpful for
jail confidentiality policies to limit sharing of self-reported health information for non-health-care purposes to only what needs to be known to
protect the health and safety of the individual and others, and to affirm that this information will not be used against the individual.
The screening process also addresses the need for continuation of prescribed medications that may present a risk for
withdrawal if not provided in a timely manner. As addressed in G-4, O-25, and O-32, prescribed opioid medications for
chronic pain or OUD treatment should be continued upon entering the jail.
Prior to continuing medication, staff should verify the prescription. With monitoring for withdrawal signs and symptoms,
it is typically safe to allow up to 24 hours to verify and then administer their prescribed medication. However, if staff are
unable to verify the prescription prior to the next scheduled dose of the medication, a provider must be notified. The
provider should make a determination whether the medication should be continued pending verification.
Prescription Verification
Medications prescribed for individuals entering jail can often be verified by checking with prescribers, pharmacies, and community databases,
such as the Prescription Drug Monitoring Program (PDMP).
• The PDMP tracks controlled substance prescriptions.

• Each state establishes who (e.g., patient, physician, physician-delegate) has access to the PDMP.
• Methadone prescriptions typically cannot be verified through the PDMP or by a pharmacist.
Memoranda of understanding (MOUs) between jails and local methadone treatment providers (e.g., opioid treatment program [OTP]) can
facilitate verification by establishing clear procedures, including contact procedures beyond the provider’s regular operating hours.

Collecting release of information from individuals on an as-needed, case-by-case basis, rather than as standard practice
at intake, is preferred. It is important that individuals entering custody understand what they are signing and are of sound
mind to make the decision to sign.
Recommendations
Referral for Immediate Clinical Assessment
As noted in the substance-specific sections, referral for immediate clinical assessment is indicated for individuals who:
• Appear unwell (including those who appear intoxicated).

• Report or are known to have used alcohol or sedatives recently, regularly, and heavily.
• Report using alcohol or sedatives in the past week and also report a history of complicated withdrawal.
• Are known to be pregnant and screen positive for alcohol or opioid use.
Transfer to a higher level of care may be necessary when clinical assessment cannot be immediately provided.
G-1. To safely and effectively identify and treat substance withdrawal, health care and custody staff should be alert to
the possibility of SUD, acute intoxication, physiological dependence, and the risk of withdrawal in all new arrivals.
A. Individuals presenting with intoxication should be presumed to be at risk for withdrawal until determined
otherwise by a qualified health care professional.
B. Individuals who exhibit potential signs and symptoms of intoxication or withdrawal, or who appear unwell to a
layperson, should be referred for immediate clinical assessment.
C. All individuals should be screened for withdrawal risk immediately upon arrival in a jail. The screening
administrator should:
i) Review recent substance use using a validated tool.
ii) Ask individuals about current SUD diagnoses.
iii) Ask individuals about their risk for substance withdrawal.
iv) A
. sk individuals reporting past-week alcohol or sedative use about their history of complicated withdrawal
(e.g., seizures, hallucinations, delirium, psychosis).
D. An individual’s report of recent, regular substance use (see substance-specific guidance), SUD, or withdrawal
risk constitutes a positive screen, even if they are asymptomatic.
G-2. Screening may be conducted by well-trained and supervised custody staff members when health care staff
are not available.
A. If the health screening is conducted by custody staff, it should begin with verbal notice that the health
screening is beginning and explain the reasons for the questions that will be asked.
B. Jails should establish policies and procedures regarding the confidentiality of information collected during the
health screening in accordance with federal, state, and local laws.

C. Staff who conduct screenings for withdrawal risk should be well-trained to inform the individuals that the
screening is being conducted for health purposes and to inform them of the confidentiality policies governing
the information they share. If confidentiality protection cannot be provided, screening for risk of withdrawal
should be conducted by a qualified health care professional.
G-3. Individuals may not be forthright about recent substance use or withdrawal risk. Therefore, custody staff should
be alert to emerging signs and symptoms of withdrawal in individuals who initially screen negative, particularly in
the first 72 hours after intake.
G-4. For individuals who enter jail while taking prescription medications associated with physiological dependence
(e.g., opioids, sedatives, anxiolytics, stimulants), health care staff should first attempt to verify the prescription.
A. Verified medications (including medications for OUD) should be continued unless otherwise ordered by a
prescriber based on documented clinical need.
B. If the medication cannot be verified, health care staff should consult with a prescriber to determine how
to proceed.
Monitoring for Withdrawal Signs and Symptoms

Individuals who screen positive for substance withdrawal risk, even if they appear well, should be monitored for the
emergence of withdrawal indicators (see table G-1).
Table G-1: Possible Indicators of Substance Withdrawal*

• Agitation • Seeming unaware of who or where they are
• Appearing severely depressed or withdrawn • Seizure
• Dilated pupils • Talking about hurting themselves or others
• Incoherent speech • Diarrhea
• Increasing anxiety or panic • Tremor
• Marked paranoia • Vital signs outside of the normal range
• Seeing, hearing, or responding to people or things not present • Vomiting
*Staff should be alert to any and all indicators of being unwell, not only those listed here.
Attentiveness to any indicator of unwellness is critical because many individuals are unable to fully report what they have
ingested due to unknown contamination with other substances.
Housing individuals at risk for or experiencing withdrawal in a dedicated unit(s) has several advantages, such as improved
monitoring and care (due to the presence of staff with a focused mission), efficiency of operations (e.g., health care staff
can make rounds more quickly), and a lower risk of diversion of treatment medications into the general jail population.
These settings may include general housing pods, special observation cells in the health services unit, or other special
housing arrangements.
The frequency and duration of monitoring summarized in table G-2 (and detailed in the substance-specific sections) are
recommended minimums. The provider may order more frequent monitoring based on the clinical assessment findings.
Likewise, qualified health care professionals may use their clinical judgment to provide more frequent monitoring. Only
a provider, through a patient-specific order, may order less frequent monitoring.

Table G-2: Withdrawal Risk Triage by Substance
Substance Refer for Immediate Clinical Assessment Monitor for Withdrawal Signs or Symptomsb
Alcohol • Appears unwell to a layperson. • Self-reported risk for alcohol withdrawal.
• Self-report of ≥8 standard drinks/day for men or ≥6 • Reports recent alcohol use below the threshold
standard drinks/day for women, ≥4 days/week. specified for immediate clinical assessment AND does
• Reports past-week alcohol use and a history of not report a history of complicated alcohol withdrawal.
complicated alcohol withdrawal (e.g., withdrawal- Monitor at least every 6 hours for the first 72 hours
related seizures, delirium, hallucinations). from arrival to facility.
Sedatives • Appears unwell to a layperson. • Self-reported risk for sedative withdrawal.
• Self-report of daily or near-daily use, and use within the • Reports recent sedative use below the threshold
past 7 days. specified for immediate clinical assessment AND
• Reports past-week sedative use and a history of does not report a history of complicated sedative
complicated sedative withdrawal (e.g., withdrawal- withdrawal.
related seizures, psychosis, hallucinations). Monitor at least every 6 hours for the first week from
arrival to facility.
Opioids • Appears unwell to a layperson. • Self-reported risk for opioid withdrawal or reports
• Clinical Opiate Withdrawal Score (COWS) ≥ 3. recent opioid use AND COWS < 3.
Monitor at least every 4 hours for the first 72 hours
from arrival to facility.
Stimulants • Appears unwell to a layperson. • Self-reported risk for stimulant withdrawal or reports
• Signs and symptoms emerge. recent stimulant use.
Monitor at least twice per day for the first 72 hours
from arrival to facility.
Recommendations
G-5. Table G-2 summarizes the substance specific recommendations for triaging individuals at risk for withdrawal. All
other individuals who screen positive for withdrawal risk should be monitored regularly for the first 72 hours after
intake and immediately referred for immediate clinical assessment and possible withdrawal management protocol
if signs or symptoms emerge or if the individual begins to appear unwell to a layperson.
A. Individuals at risk for withdrawal should ideally be housed together in a dedicated unit to facilitate monitoring.
G-6. Monitoring should only be discontinued early based on a patient-specific order from a provider.
G-7. Monitoring may be conducted by a qualified health care professional or well-trained and supervised custody staff
(see Staffing and Staff Training).
G-8. Both custody and health care staff should encourage individuals at risk for substance withdrawal to report
emerging withdrawal symptoms to staff. If patients report that they are starting to experience withdrawal, they
should be referred for immediate clinical assessment.
A. Jails should train all staff to be responsive when an individual self-reports withdrawal symptoms. This should
include referral for immediate clinical assessment.
G-9. Individual differences in metabolism, liver function, and kidney function can cause some individuals to take longer
to go into withdrawal than expected. If withdrawal-like symptoms emerge after the monitoring period has ended,
the individual should be referred for immediate clinical assessment.
b
For individuals who appear well to a layperson

G-10. Since the supply of illicit drugs is increasingly contaminated or mixed with opioids, some individuals may not
be aware that they have been using opioids. Custody staff should be alert to potential opioid withdrawal signs
and symptoms that begin within 72 hours of incarceration (see table G-2). Individuals showing these signs or
symptoms, or appearing unwell to a layperson, should be referred for immediate clinical assessment.
Clinical Assessment and Diagnosis

Unlike screening, clinical assessment is conducted only by qualified health care professionals, who focus first on
establishing substance intoxication or withdrawal as the likely and primary cause of any findings. They collect vital signs,
take medical and psychiatric history, and evaluate the individual for signs of other physical or mental health conditions to
help determine withdrawal-related risks and risk for complications. For example, the use of more than one substance or
underlying psychiatric conditions may complicate management of the withdrawal syndrome. Telehealth may be used to
support clinical assessment. Well-trained custody staff can provide support for onsite tasks, such as taking vital signs. The
telehealth provider is responsible for determining if telehealth is appropriate or when an in-person visit is needed.
Drug testing may be considered to corroborate self-reported information. Note that toxicology screens may fail to detect
all substances consumed. (For example, standard panel drug tests do not detect fentanyl, which may reduce alertness
among staff to withdrawal signs and symptoms associated with opioids.). ASAM’s Principles of Drug Testing During
Withdrawal Management are summarized in appendix D. For more information, review ASAM’s Appropriate Use of Drug
Testing in Clinical Addiction Medicine.
Scope of Practice
Registered nurses are qualified to conduct and document clinical assessments, following physician-approved protocols defining when
coordination with an on-call provider must take place, such as in making diagnoses and initiating treatment plans. (Note: Nurse practitioners and
physician assistants are allowed to diagnose and initiate treatment.)
Results of the clinical assessment inform the diagnosis (as guided by criteria in the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders), the duration and frequency of monitoring, the withdrawal
management plan (including medications if needed), and the need for transfer to a higher level of care, as summarized in
table G-3.
Table G-3: Assessment and Action

Assess withdrawal risk level based on:
• Current substance use (frequency, dose, duration, route, time of last use, etc.).
• Signs and symptoms.
• History and severity of prior withdrawal.
• Medical and psychiatric comorbidities.
• Psychiatric history, including suicidality.
Conduct onsite withdrawal management when:
• The jail can manage the anticipated severity of the withdrawal syndrome and any medical or psychiatric comorbidities.
• Medications and monitoring can be carried out per substance-specific clinical orders.
• A supportive environment with access to hydration, nutrition, and sleep can be provided.

Table G-3: Assessment and Action (continued)
Consider transfer to a higher level of care when:
• History of severe or complicated withdrawal is identified.

• Moderate to severe withdrawal from multiple substances is anticipated.
• History of severe psychiatric symptoms is identified.
• A pregnant patient may be at risk for alcohol or opioid withdrawal.
Transfer to a higher level of care when:
• Nursing, medical, or psychiatric resources recommended in this guideline are not immediately available.
• Overdose is suspected.
• Significant signs and symptoms persist despite multiple doses of medication.
• Severe signs or symptoms develop during withdrawal management.
• Existing medical or psychiatric condition worsens.
• Unstable vital signs do not respond to medications.
• There is severe or ongoing oversedation.
• There is moderate to severe withdrawal with significant comorbidity.
• Alcohol or sedative withdrawal is severe.
• Complicated symptoms (seizures, delirium, hallucinations) exist.
• Wernicke encephalopathy is known or suspected.
• A patient cannot take required medication orally, and there is no capacity to provide medication by another route.
• Severe psychiatric symptoms are present, and a mental health assessment cannot be immediately provided.
• Barbiturate or gamma-hydroxybutyric acid (GHB) withdrawal is known or suspected.
• The treatment plan as recommended by a qualified health care professional cannot be adequately or safely managed in the jail.
• Acute medical signs or symptoms cannot be safely managed.
Recommendations
G-11. All individuals who are referred for immediate clinical assessment for substance withdrawal should be assessed by
a qualified health care professional.
G-12. The initial clinical assessment should:
A. Identify any emergent medical or psychiatric needs.
B. Evaluate current withdrawal signs and symptoms.
C. Evaluate risk for severe or complicated withdrawal.
D. Assess risk for suicide.
E. Determine the appropriate level of care.
G-13. All individuals at risk for withdrawal should be assessed for SUD.
G-14. If patients are unable to engage in the full clinical assessment due to intoxication or withdrawal, they should
be assessed for immediate clinical needs. The full assessment should be completed once their intoxication or
withdrawal symptoms have resolved.

Level of Care
There is wide variation across jails in onsite medical, mental health, and nursing staffing and capacity to handle serious,
complex, and urgent health care needs. Where treatment services and resources are recommended in this guideline,
including buprenorphine and methadone treatment, and are not immediately available in the jail, timely transfer to a
higher level of care is indicated.
Each facility should establish clear policies on determining when to provide services in-house or to transfer to a facility
equipped to provide the necessary level of care. Recommendations involving a higher level of care apply to individuals
who are already incarcerated in the jail, as well as those who are newly arriving.
Hospitals are obligated, under the Emergency Medical Treatment and Labor Act, to provide stabilizing treatment for
patients with emergency medical conditions. Most individuals, once stabilized, can safely be readmitted to the jail. When
this is not the case, clear policy and procedures on readmittance (established with the input of the sheriff or jail director,
county administrators, hospital officials, and the jail health authority) will help prevent unsafe and needless transport.
The transferring party (e.g., hospital) and the accepting party (i.e., jail) must agree that the accepting party can provide
the required ongoing care. The hospital should not assume jails have the staff capacity to monitor and support proper
care for the patient upon discharge. It is important to establish a strong working relationship between hospital and jail;
this may be supported through an MOU between the local hospital and the jail. An established relationship should
facilitate effective communication regarding the jail’s health care capabilities and what the jail needs to safely accept
patients who require ongoing care (e.g., documentation, medical orders, access to specialty medications).
If the jail does not have the ability to safely manage care, the patient should be returned to a medical facility. In other
words, “clearance” by an external medical authority should not be automatically accepted by the jail when medical or
common sense dictate otherwise and should be considered subject to change if the individual’s condition changes. Jails
are encouraged to seek counsel in developing policies and procedures regarding when to refuse an individual returning
from a medical facility.
Clinical needs do not justify loss of privileges. If the physical layout of the jail demands transfer of the patient to a more
restrictive area when close clinical monitoring is indicated, the impact on privileges should be carefully considered
and minimized.
Recommendations
G-15. T
. he level of care in which withdrawal management is provided should be appropriate for the anticipated severity
of the withdrawal syndrome, as well as any medical or psychiatric comorbidities present, and should be adequate
to provide the treatment services and monitoring needed to facilitate safe and effective care.
G-16. A patient who presents with severe psychiatric symptoms, including hallucinations, delusions, paranoia, and
delirium, should be immediately transferred to a higher level of care unless a physician experienced in differential
diagnosis and management of acute changes in mental status is immediately available for clinical assessment and
stabilization.
A. If feasible and clinically indicated, medications should be provided to stabilize the patient concurrent with the
call for transport.

G-17. See substance-specific guidance regarding frequency of clinical assessments. If health care staff are not available
onsite to manage the minimum required frequency of clinical assessments, the patient should be transferred to
an appropriate medical facility. (Note that well-trained and supervised custody staff may monitor withdrawal signs
and symptoms and administer validated tools, such as the COWS and CIWA-Ar.)
G-18. Where nursing, medical, psychiatric, or urgent care resources are recommended in these guidelines and are not
immediately available onsite, the provider should be consulted to determine the necessary timing for transferring
the patient to a higher level of care for further assessment and treatment.
A. If a provider is not available, the patient should be immediately transferred to a hospital.
G-19. For management of suspected substance overdose, follow the principles of first aid and cardiopulmonary
resuscitation (CPR) and transfer to a local emergency department.
A. If the patient is not breathing, or their breathing is not sufficient, naloxone should be administered.
Withdrawal Management by Qualified Health Care Professionals

Recommendations
G-20. Medical decisions should be independent of the custody level or classification of the patient.
G-21. While comprehensive clinical assessment of the patient is critical for treatment planning, treatment should not be
delayed while awaiting completion of all assessments or laboratory testing or results.
G-22. Any protocols or similar guidance used in withdrawal management should reflect current clinical treatment
standards and be approved by the responsible provider with input from a physician with withdrawal management
expertise as appropriate.
G-23. Some patients may be released from jail prior to completion of withdrawal management. However, treatment
should not be delayed based on the potential timeline for release.
G-24. A provider should receive a daily census of all patients being monitored or treated for substance withdrawal and
review the status of all patients being monitored for acute withdrawal daily.
G-25. Withdrawal from alcohol, sedatives, and opioids can be dangerous and potentially life-threatening. The intensity
of withdrawal cannot always be predicted. Frequent clinical assessments should be conducted by qualified health
care professionals based on patient-specific orders from the provider.
A. These clinical assessments should be conducted by qualified health care professionals not less than twice
per day, not more than 16 hours apart, unless otherwise stated in the substance-specific guidance in this
document.
B. Unless otherwise ordered by the provider, during each clinical assessment, a qualified health care professional
should evaluate:
i) General physical condition.
ii) Vital signs.

iii) Hydration.
iv) Orientation.
v) Sleep.
vi) Mental health status including risk for suicide and self-harm.
vii) Fall risk.
viii) Progression of the patient’s withdrawal symptoms.
ix) Timing of the next assessment.
G-26. Withdrawal syndromes and the medications used to manage withdrawal can put patients at risk for falls. It is
recommended that patients undergoing withdrawal management be assigned lower bunks and housed on
lower floors.
G-27. Management of withdrawal does not constitute treatment for SUD. Jails should take proactive steps to engage
patients with SUD in ongoing treatment, as described in Reentry.
Monitoring Patients During Withdrawal Management

Regularly monitoring patients helps staff detect destabilizing health, enabling providers’ timely modification of treatment
plans. Telehealth may be used to provide a broad range of clinical services, depending on what technologies are available
and the needs of the patient. It is the provider’s responsibility to determine when telehealth is or is not appropriate.
Consider the timing of monitoring to avoid interfering with the normal sleep schedule of the person being assessed,
unless specifically ordered otherwise by the qualified health care professional.
Recommendations
G-28. All patients undergoing withdrawal from any substance should be monitored regularly for changes in condition.
Monitoring should be conducted by qualified health care professionals or well-trained and supervised custody
staff (see Staffing and Staff Training).
G-29. The onset and intensity of withdrawal is variable. The frequency and duration of monitoring should be determined
based on the type of substance taken, when it was last taken, and the suspected duration of effect. Frequency of
monitoring should be determined by a qualified health care professional.
A. See respective substance-specific section for monitoring intervals (see appendix E for summary of
recommendations).
B. The frequency of monitoring and assessment discussed in this document is the minimum recommended for the
patients described. Clinical staff should use their judgment to determine when more frequent assessment or
monitoring is needed.
C. The frequency of monitoring or assessment should not be decreased or discontinued without a patient-specific
order from a physician.

G-30. If qualified health care professionals are not onsite, well-trained and supervised custody staff should monitor
patients undergoing withdrawal management based on patient-specific instructions from a provider.
A. Custody staff should not be expected to make decisions about the severity or implications of changes in
patient condition. Rather, the patient-specific instructions should describe what should be monitored (e.g.,
changes in appearance, mental status, behavior, vital signs, score on a validated tool), what changes to
look for, and what to do if those changes are noted (e.g., when to contact the on-call qualified health care
professional, when to seek emergency medical care).
B. If a patient’s condition appears emergent to the layperson, emergency assistance should be obtained
immediately.
G-31. Jails should consider housing individuals who will be monitored for withdrawal risk or withdrawal management in
a unit dedicated for this purpose.
G-32. In jails without a dedicated housing unit for withdrawal management, an accurate and current log of all patients
being monitored for withdrawal risk and withdrawal management should be maintained including, at a minimum,
the substance(s) for which monitoring is being conducted and the frequency of monitoring.
G-33. Monitoring may be discontinued when the patient is no longer showing signs or symptoms of withdrawal without
medications and a patient-specific order is written by a provider.
Medications
The effectiveness of pharmacotherapy for withdrawal from certain substances is well established, such as
benzodiazepines for alcohol withdrawal and buprenorphine or methadone for opioid withdrawal. (For a summary of
pharmacotherapy per substance, see appendix F.)
Medication used to manage withdrawal must be ordered by a licensed prescriber for a specific patient. However, a
prescriber order is not required to administer naloxone, a medication used to reverse opioid overdose. Correctional
and health care staff alike should be well-trained to regard naloxone as a life-saving tool for opioid overdoses, much
like automated external defibrillators have become standard features in workplaces to respond to cardiac arrest. Note
that multiple doses of naloxone may be needed, and individuals with OUD may experience withdrawal symptoms after
receiving naloxone.
Recommendations
G-34. There is significant variation in the timing and intensity of withdrawal, as well as response to medications. This
variance is related to both the characteristics of the patient’s substance use and individual genetic differences in
substance metabolism. Treatment plans, including medications, should be individualized.
G-35. Any prescription medications provided for withdrawal management should be ordered for the patient by a
prescriber.
A. This does not preclude the inclusion of prescription medications in a withdrawal protocol or pathway. However,
a prescriber must order implementation of a specific withdrawal protocol or pathway for a specific patient.

G-36. Medications for specific withdrawal syndromes are discussed in the relevant sections of this document.
Medications may also be provided for common symptoms of withdrawal, as needed, using standard doses unless
otherwise contraindicated.
A. Nursing protocols may be used to provide guidance regarding provision of over-the-counter medications.
G-37. Naloxone should be readily available to custody and medical staff for overdose reversal, including in all housing units.
G-38. Jails should consider making naloxone readily available in all housing units to individuals who are in custody.
Staffing and Staff Training

Building a sense of teamwork between custody and health care staff facilitates a unified response to substance
withdrawal. Jail administrators can support this relationship by setting clear policies and protocols on the roles and
responsibilities of both custody and health care staff and supporting these policies through training. For example, it is
not within the purview of custody staff to diagnose or determine the cause of signs or symptoms; qualified health care
professionals make these determinations.
Recommendations
G-39. Jails lacking expertise in withdrawal management, SUD, and overdose risk should consider establishing
relationships with external experts, including local public health and state substance use treatment authorities, to
help establish effective protocols for managing these issues.
G-40. To support management of substance withdrawal, it is recommended that jails, at minimum, have 24-hour, on-call
clinical support (at minimum, a registered nurse). This can be accomplished through any combination of onsite
health care staff, remote coverage, telehealth services, and/or transfer to facilities that can provide a higher level
of care.
G-41. Custody staff should be well-trained to make an immediate referral to medical services when they observe
potential signs and symptoms of withdrawal, or an individual otherwise appears unwell, and when an individual
reports experiencing withdrawal.
G-42. If custody staff may be called upon to screen for withdrawal risk, they should be well-trained to conduct
screenings, to recognize the signs and symptoms of withdrawal, and to follow established protocols to ensure
rapid provision of medical services for patients in or at risk for withdrawal.
G-43. Custody staff may be trained to effectively administer withdrawal severity tools (such as the COWS and CIWA-Ar),
including collection of vital signs, and to coordinate care with an on-call registered nurse based on established
protocols when health care staff are not available.
G-44. Training for custody staff who conduct screening for withdrawal risk or administer withdrawal severity tools should
be provided by a qualified health care professional assigned this task by the health services administrator or the
responsible provider.
G-45. All staff who conduct screenings or assessments should be assessed at least yearly for competence in performing
these tasks.
G-46. The trainer or a supervisor should observe real-patient interviews as part of both initial and refresher training to
ensure competency.

G-47. All custody staff should receive training that addresses the misconceptions and stigma regarding SUD, SUD
treatment, and the use of medications to treat OUD.
G-48. The jail’s first aid course should include training on giving CPR; managing overdose (checking respirations,
positioning patient to avoid aspiration, and administering naloxone); and managing seizures (preventing head
trauma, positioning the patient to avoid aspiration) while awaiting emergency medical services (EMS).
G-49. All training relevant to these guidelines should be repeated at least every 2 years.
G-50. Policy and procedures for staff training should be reviewed at least every 2 years.
Additional staff training is noted in the substance-specific sections.
Quality Assurance
Quality assurance is essential for effectively implementing these guidelines. Quality assurance should involve both
custody and health care staff and include structured procedures. Ideally, meetings would take place to review data and
minutes reflecting actions taken.
Recommendation
G-51. Jails should establish a quality assurance process for withdrawal management in their facility.
Supportive Care
Supportive care for withdrawal helps alleviate common physical complications and reassures the patient about what to
expect from the process. For example, minimizing environmental stimulation (e.g., dimming lights, reducing noise levels)
and housing patients experiencing withdrawal in smaller units (when available) may make withdrawal less physically and
emotionally challenging. Isolating patients who are experiencing withdrawal, however, is not advised, due to the
increased risk of self-harm (see G-63).
In addition, vomiting and diarrhea can occur during withdrawal. Dehydration and electrolyte imbalances can have serious
health consequences, including death, so maintaining fluids is essential (see G-54). It is important that custody staff are
alert to indicators of dehydration (see appendix G) and well-trained to report concerns about dehydration to health care
staff. Qualified health care professionals will monitor for signs and symptoms of dehydration during clinical assessments.
On a broader level, supportive care encompasses all programming and resources that facilitate a patient’s journey to
recovery from SUD. It is important for patients to understand that treatment of withdrawal is not treatment of SUD.
The length of stay in jail will impact the nature of supportive care and may include Motivational Interviewing and other
counseling, stress management strategies, education on making lifestyle changes, and mutual support/peer support
programs. Of note, some jails use telehealth to provide individual and group counseling sessions (see Telehealth
Resources).9
Recommendations
G-52. All patients experiencing withdrawal, regardless of severity, should receive supportive care, which may include
nutritional supplementation, intravenous (IV) fluids, glucose, management of electrolyte abnormalities, and
periodic clinical reevaluations, as clinically indicated (see Monitoring Patients During Withdrawal Management).

G-53. Patient education regarding the withdrawal process is a necessary component of treatment. Patients experiencing
withdrawal should be counseled on:
A. The signs and symptoms of withdrawal.
B. The assessment process.
C. What to expect during treatment and monitoring.
D. What to do if they are released prior to completion of withdrawal management.
E. The patient’s role in helping to manage withdrawal (e.g., staying hydrated, communicating with health care and
custody staff).
F. The importance of engaging in ongoing SUD treatment to support sustained recovery.
G-54. Unless restricted access is ordered by a provider and the patient is placed under close medical supervision,
patients experiencing withdrawal should have unimpeded access to water or electrolyte solution.
A. Both health care and custody staff should encourage patients to stay well-hydrated.
B. Custody staff should notify health care staff if they notice that a patient undergoing withdrawal management
has insufficient fluid intake or is refusing to drink.
Reentry
Reentering the community is a challenging time for individuals, especially for those with SUD. Research shows that
risk of overdose in the 2 weeks following release from incarceration is extremely high.10 Patient education on the risks
associated with reduced tolerance to substances as a result of withdrawal and how this might lead to overdose and death
is important for mitigating these risks. This topic is further discussed in Opioid Withdrawal.
Ideally, individualized reentry plans that address ongoing withdrawal management needs, SUD treatment engagement,
overdose prevention, and recovery supports are developed with appropriate input from the health care provider for all
patients with SUD. These plans include assertive referrals (i.e., scheduling appointments for community care), as well as
strategies for:
• Appropriate sharing of health records (electronic or paper) as authorized by state law.
• Establishing insurance coverage including support for enrollment or re-activation of suspended or terminated
Medicaid coverage (if applicable).
• Arranging patient navigator support or collaborating with community substance use treatment, such as providers
who are willing to meet people upon release or provide in-reach services to facilitate transition. The value of patient
navigators with lived experience in incarceration and SUD may be realized in improved relationships with treatment
providers, increased treatment retention, decreased criminal justice involvement, reduced relapse rates, and
reduced substance use, among other outcomes.11
However, reentry plans may not be possible for patients who are in jail for only a few hours or days. At minimum, all
patients treated for withdrawal should be provided information on where they can follow up in the community upon
release to obtain withdrawal management or SUD treatment services; when feasible and allowed, they should also

receive a sufficient quantity of medication to sustain them until the next appointment. This is particularly important for
patients who are treated with buprenorphine or methadone, which can be difficult to access. Providing a prescription
for prepaid medication at a local pharmacy to patients reentering the community may be an option for jurisdictions
to explore.
In developing protocols for releasing patients from confinement with ongoing urgent or emergent medical needs who
do not have decisionmaking capacity or competency, staff should seek out advice from counsel to ascertain appropriate
release protocols in accordance with federal, state, and local laws and regulations.
Recommendations
G-55. As discussed in Withdrawal Management by Qualified Health Care Professionals, some patients may be released
from jail prior to completion of withdrawal management. Disruption of treatment could place the patient at risk
for serious health consequences and death. At the start of treatment, qualified health care staff should provide
patients with information regarding community resources where they can continue withdrawal management
services and initiate or continue SUD treatment services.
A. Where time permits, qualified health care professionals should establish a discharge plan that is in place
throughout withdrawal management which outlines appropriate care upon release.
G-56. Patient navigation services may be helpful for facilitating engagement in care upon release from jail. Jails and/
or partnering community agencies should consider providing well-trained patient navigators prior to release to
support patient engagement in community treatment.
A. This is particularly important for patients receiving methadone or buprenorphine for the treatment of opioid
withdrawal or OUD as these services can be difficult to access. If provided, navigators should be trained to
maintain backup plans and emergency contacts to prevent interruption of post-release treatment.
B. Because patient navigators are often individuals with lived experience with SUD and/or incarceration, jails
should review their security protocols to consider allowing individuals with lived experience, who may typically
not be permitted to enter the facility, to perform this role, consistent with security protocols.
G-57. When patients who have decision-making capacity are being released with ongoing emergent medical needs,
they should be informed of the related medical risks by a qualified health care professional and offered
transportation to a hospital.
G-58. When patients who do not have decision-making capacity are released with ongoing emergent medical needs,
they should be transferred to an appropriate medical facility in accordance with federal, state, and local laws and
regulations.
G-59. Every effort should be made to ensure continuity of care by sharing health records with the patient’s community
provider(s), in accordance with applicable federal, state, and local laws and regulations.
A. Shared health records should have sufficiently detailed clinical information to allow for continuity of care; a
discharge report containing only the patient’s medication and problems list is insufficient.
B. If the jail cannot establish communication with the patient’s community provider, the jail should provide the
patient with either a discharge report with sufficient clinical detail to support continuity of care or instructions
on how the patient’s community provider can contact health care staff.

C. Jails should have policies and procedures that support continuity of care through sharing of health records and
clinical information with community providers.
Suicide
Screening for suicide risk regularly throughout the withdrawal process is advised due to the rapidity at which suicidal
ideation can evolve. The instruments available for screening for suicide risk have only been validated in a community
setting; no instrument has been validated in a correctional population at the time of this publication. Therefore, caution
should be used when interpreting the results. It is important for jails to have policies and protocols regarding the safety of
individuals identified as at risk of self-harm and that define the frequency and duration of wellness checks while in custody.
Depression may be a consequence of withdrawal; however, depression that does not improve as the withdrawal
syndrome improves may require evidence-based depression treatment.
Recommendations
G-60. The frequency of suicide attempts is substantially higher among patients with SUD, including those without a pre-
existing psychiatric condition. Suicide risk, with particular attention to thoughts of self-harm, should be evaluated
as part of the initial patient assessment and each subsequent clinical assessment during withdrawal management
using a validated tool.
G-61. Management of patients at risk for suicide should include reducing immediate risk, managing underlying factors
associated with suicidal intent, and monitoring and follow-up care as directed by a qualified mental health care
professional.
G-62. Frequent safety checks should be implemented; the frequency of these checks should be determined by a
qualified mental health professional with consideration for increased frequency when signs of depression, shame,
guilt, helplessness, worthlessness, or hopelessness are present.
G-63. Isolating patients who are experiencing withdrawal is not recommended due to the increased risk of self-harm.
Pregnancy and Postpartum

Substance withdrawal can pose risks to both the pregnant patient and the fetus, which may necessitate a higher level
of care. The substance-specific guidance in this document provides recommendations to guide care, and as discussed
further in Opioid Withdrawal, a higher level of care (e.g., a hospital or medically managed residential program with an
obstetrical provider) should be considered for pregnant patients during initiation of methadone or buprenorphine.
Medications used to treat withdrawal, including benzodiazepines, can pose risks to the fetus, but the risks of unmanaged
withdrawal often outweigh these risks. Pregnant patients should receive a judgment-free explanation of the risks and
benefits of available options for withdrawal management (see G-69), while being sensitive to the overlapping stigma and
judgment pregnant patients who use substances and are incarcerated face. Pregnant patients may decline medications
based on perceived or discussed risk to fetus, but medications that treat withdrawal should not be withheld based on the
patient’s pregnancy or lactation status.
Some states have laws requiring health care providers to report positive drug test results or to notify child protective
services when infants are born affected by prenatal alcohol or drug use (e.g., Child Abuse Prevention and Treatment
Act [CAPTA]). Qualified health care professionals should educate pregnant patients regarding these risks and, when

appropriate, obtain informed consent prior to conducting any health care-related drug testing. The intent of the
notification is to ensure that the patient understands the requirements without conveying judgment.
Withdrawal during pregnancy is also associated with high rates of return to use,12 which can lead to harm to the fetus,
including the return to alcohol use that can result in fetal alcohol spectrum disorders (FASD), overdoses, and other harms.
Efforts should be made to engage all pregnant patients treated for withdrawal in ongoing SUD treatment. For pregnant
patients with OUD, the standard of care is ongoing treatment with buprenorphine or methadone.
Jails should establish policies and protocols related to withdrawal management during pregnancy. These policies and
protocols should be developed and approved by a physician or physicians with experience in SUD and obstetrics and
communicated to all facility and community decision-makers, from arrest through reentry.
Additionally, jails are encouraged to establish policies and procedures for distributing naloxone or providing
prescriptions for naloxone to patients, including those who are pregnant or postpartum, as they leave custody to reenter
the community.
Recommendations
G-64. All patients of childbearing potential or childbearing age should be assessed for pregnancy and offered
pregnancy testing.
G-65. Health care professionals and custody staff should not assume symptoms such as nausea, headache, anxiety, and
insomnia are due to pregnancy and should remain vigilant for substance withdrawal.
G-66. When offering medications to pregnant or lactating patients to treat substance withdrawal or medical
complications of withdrawal, the prescriber should discuss the risks and benefits of each medication for the
patient and the fetus or infant, as well as risks associated with untreated withdrawal and ongoing substance use
during pregnancy.
G-67. Initiation and continuation of medication should not be withheld or delayed due to a patient’s pregnancy or
lactation status.
G-68. Health care professionals should follow the recommendations included in the substance-specific sections on
treating withdrawal in pregnant patients.
G-69. Some states have laws that require health care providers to report positive drug test results and impose adverse
legal and social consequences on individuals who use substances during pregnancy. Therefore, qualified health
care professionals should educate pregnant patients regarding these risks and obtain informed consent prior to
conducting any health care-related drug testing.
Older Adults
Approximately 8 percent of adults confined in local jails are age 55 and older,13 a cohort referred to in this document
as “older adults.” Fifty-five years is used in this context because heavy substance use, inadequate health care, and the
stress of incarceration itself contribute to accelerated aging, which means that individuals may have physical and mental
conditions that are typically associated with those who are at least 10 years older.14 Hypertension, diabetes, angina, heart
attacks, arthritis, and hepatitis are more prevalent among individuals in jail custody who are ages 50–65 than those in the
same age group who are not incarcerated.15

Withdrawal management in older adults can be complicated by the higher prevalence of chronic diseases that impact
withdrawal management (e.g., heart disease, lung disease); slower metabolism of medications; blunted physiological
responses that can affect the validity of monitoring tools such as the COWS; and misinterpretation of cognitive changes
associated with withdrawal as being due to dementia.
In general, the treatments discussed in this guideline are applicable to older adults; however, medications to manage
withdrawal should be modified to account for age-related factors, such as increased sensitivity to medications, drug-
drug interactions, or co-existing conditions. For example, long-acting benzodiazepines are not necessarily preferred in
older patients for managing alcohol withdrawal due to the risk of accumulation leading to oversedation and respiratory
depression.16 Withdrawal may also take longer due to slower metabolism among older adults.
Recommendations
G-70. Management of withdrawal in older adults may require increased monitoring for side effects and/or lower
medication dosages.
A. The recommendations presented in this document for management of withdrawal from alcohol, sedatives,
opioids, and stimulants are generally applicable to older adults as long as sensitivity to medications and drug
interactions are considered.
B. The threshold for transferring an older adult patient to a community facility and/or higher level of care for
withdrawal management should be lower than it is for younger adults.

Alcohol Withdrawal
Alcohol withdrawal left undetected, unmonitored, and untreated can lead to seizures, delirium, and death.
Screening
There is no established threshold of alcohol use that confers risk for serious or complicated alcohol withdrawal. The
expert committee (EC) reviewed the available research literature and, after finding a lack of conclusive data, drew
on their collective professional experience and expertise to recommend a level of alcohol use that should trigger an
immediate clinical assessment (see A-2).
A standard drink in the United States is defined as

approximately 14 grams of pure alcohol, which is found in
12 fluid ounces of regular beer, 5 fluid ounces of wine, or
1.5 fluid ounces of distilled spirits (see exhibit 1).
For individuals who are unable to provide an alcohol use

history, a toxicological test can measure blood alcohol
concentration (BAC) or breath alcohol concentration
(BrAC), thereby detecting recent use of alcohol.
Toxicological testing can also help differentiate between
alcohol intoxication and sedative intoxication, which
can have a similar presentation (e.g., slurred speech,
poor physical coordination). However, it is important to
understand that BAC/BrAC results alone do not establish Exhibit 1: U.S. standard drink equivalents (Adapted from National Institute on
risk for withdrawal. For example, patients can have a Alcohol Abuse and Alcoholism)
negative result and still be at risk for alcohol withdrawal.
Recommendations
A-1. If an individual appears intoxicated and/or a corrections-administered breathalyzer test suggests intoxication, the
individual should be referred for immediate clinical assessment.
A-2. Individuals reporting or known to be using alcohol recently, regularly, and heavily (eight or more standard drinks
per day for men and six or more standard drinks per day for women, 4 or more days per week) should be referred
for immediate clinical assessment and possible withdrawal management protocol.
A-3. Individuals who report using any alcohol in the past week and also report a history of complicated withdrawal
should be referred for immediate clinical assessment.

Typically, signs and symptoms of alcohol withdrawal (see table A-1) emerge 6–24 hours after the last drink of alcohol, with
more severe indicators starting later, such as alcohol withdrawal delirium (formerly known as “delirium tremens”), which
may emerge 72–96 hours after the last drink.17
Table A-1: Possible Indicators of Alcohol Withdrawal*18

Many conditions listed below are expected responses to incarceration but, when presented as part of a constellation of symptoms, may indicate
alcohol withdrawal.
• Agitation‡ • Loss of appetite
• Anxiety or nervousness • Mood swings
• Depression • Nausea and vomiting
• Difficulty thinking clearly • Nightmares
• Fatigue • Pallor
• Fever‡ • Rapid heart rate
• Hallucinations‡ • Elevated blood pressure
• Insomnia • Seizures‡
• Headache • Severe confusion‡
• Irritability • Sweating, clammy skin
• Jumpiness or shakiness • Tremor of the hands or other body parts
*Staff should be alert to any indications that an individual is unwell, not only those listed here.
‡
Indicative of alcohol withdrawal delirium
Recommendations
A-4. Individuals who self-report risk for alcohol withdrawal and who report alcohol use below the threshold specified in
recommendation statement A-2 should be monitored at least every 6 hours for the emergence of withdrawal signs
and symptoms.
A. As discussed in The Withdrawal Management Process, if signs or symptoms emerge or if the individual begins
to appear unwell to a layperson, the individual should be referred for immediate clinical assessment.
A-5. Custody staff who perform regular health and wellbeing checks should be alert to the emergence of withdrawal
signs and symptoms and well-trained to make immediate referrals for medical care if the individual appears unwell.

As discussed in The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management, alcohol withdrawal severity
assessment scales, such as the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar), are
designed to assess withdrawal after a diagnosis has been established. High scores may be indicative of other conditions
(e.g., dehydration, fever from infection, Graves’ disease).
Recommendations
A-6. The clinical assessment should:
A. Rule out other serious illnesses that can mimic the signs and symptoms of alcohol withdrawal.
B. Determine if the patient is taking medication that can mask the signs and symptoms of alcohol withdrawal.

A-7. Alcohol withdrawal severity assessment scales (including the CIWA-Ar) should not be used as stand-alone
diagnostic tools because scores can be influenced by conditions other than alcohol withdrawal.
A-8. Alcohol withdrawal can progress rapidly with serious health consequences. Individuals referred for immediate
clinical assessment should be assessed immediately by a qualified health care professional to determine their risk
for developing severe and/or complicated alcohol withdrawal or complications from alcohol withdrawal.
A. In addition to signs and symptoms of alcohol withdrawal, the following factors are associated with increased
patient risk for complicated withdrawal or complications of withdrawal and should be assessed:
i. History of complicated alcohol withdrawal (e.g., delirium or alcohol withdrawal seizure).
ii. Multiple prior withdrawal episodes.
iii. Comorbid illnesses (especially traumatic brain injury).
iv. Age > 65.
v. Marked autonomic instability on presentation.
vi. Long duration of heavy and regular alcohol consumption.
vii. Seizure(s) during the current withdrawal episode.
viii. Physiological dependence on sedatives such as benzodiazepines or barbiturates.
ix. Positive blood alcohol concentration in the presence of signs or symptoms of withdrawal.
A-9. If a toxicology test (blood, breath, or urine) for alcohol use is used, do not rule out the risk of developing alcohol
withdrawal if the test result is negative.
Withdrawal Management by Qualified Health Care Professionals

Historically, alcohol has been administered to prevent withdrawal in some cases. However, administration of oral or IV
alcohol has no proven efficacy, no accepted protocols, and can be toxic.
Recommendations
A-10. Oral or IV alcohol should not be used for the prevention or treatment of alcohol withdrawal.

During withdrawal management, monitoring typically includes both collection of vital signs and administration of a
validated severity assessment scale, such as the CIWA-Ar (see table A-2).
Table A-2: Alcohol Withdrawal Severity19

Severity Category Mild Moderate Severe Complicated
Associated CIWA-Ar Range < 10 10–18 ≥ 19 ≥ 19

As alcohol withdrawal is primarily treated with benzodiazepines, which are sedative medications, it is important that staff
monitor for and report oversedation.
Recommendations
A-11. Alcohol withdrawal severity should be monitored using a validated tool, such as the CIWA-Ar.
A-12. Use of the CIWA-Ar does not replace a clinical assessment, including collection of the patient’s vital signs.
A-13. A clinical assessment including the CIWA-Ar should be conducted at least every 8 hours during alcohol
withdrawal treatment until the CIWA-Ar score remains below 10 for 24 hours.
A. If the CIWA-Ar is > 19, repeat the CIWA-Ar at least every 6 hours during alcohol withdrawal treatment until the
score falls below 19, then continue monitoring with the CIWA-Ar at least every 8 hours until the score remains
below 10 for 24 hours.
B. More frequent monitoring should be conducted if clinically indicated.
A-14. To support management of alcohol withdrawal, a qualified health care professional, or custody staff, who has
been well-trained to administer the CIWA-Ar (or another validated tool) should be available at all times.
A-15. Custody staff should be well-trained to identify oversedation and to alert health care staff if a patient appears
oversedated.
A-16. Regular clinical assessments should monitor for dehydration. Health care staff should be alerted if the patient
reports, or custody staff otherwise become aware, that the patient has stopped drinking, has a significant
reduction in urine volume or frequency of urination, or has very dark urine.
Level of Care
Severe alcohol withdrawal can result in serious health consequences, including death. The clinical assessment should
inform the determination of whether the predicted severity of withdrawal can be managed in the jail or transfer to a
hospital is indicated.
Table A-3: Signs and Symptoms of Wernicke Encephalopathy–Korsakoff Syndrome20

Wernicke Encephalopathy Korsakoff Syndrome
• Confusion or loss of mental activity. • Inability to form new memories.
• Loss of muscle coordination (ataxia), manifested as leg tremor or • Loss of memory, can be severe.
wide-based or unsteady gait. • Making up stories (confabulation).
• Vision changes:
o Abnormal eye movements (back and forth movements
called nystagmus).
o Double vision.
Recommendations
A-17. Level-of-care determination should be based on a patient’s risk for developing severe or complicated alcohol
withdrawal, or complications of withdrawal, as well as current signs and symptoms.
A-18. If the patient requires transfer to a higher level of care, treatment for immediate needs should be initiated while
awaiting transfer, where feasible.

A-19. While most patients experiencing alcohol withdrawal may be managed in the facility, if the following indications
are present, the patient should be transferred to a hospital (unless the jail has hospital-level capacity):
A. Agitation or severe tremor persists despite having received multiple doses of medication.
B. Severe signs or symptoms, such as persistent vomiting, marked agitation, hallucinations, confusion, or seizure,
develop.
C. Existing medical or psychiatric condition worsens.
D. Unstable vital signs (low/high blood pressure or heart rate) that are not responsive to medications provided to
treat withdrawal.
E. Severe or ongoing oversedation.
F. Patient has moderate or high CIWA-Ar scores and significant comorbidity.
A-20. Patients with severe withdrawal (CIWA ≥ 19) or complicated symptoms (e.g., seizures, delirium, hallucinations)
should typically be transferred to a setting with 24-hour medical care available, (e.g., an emergency department
or hospital).
A. For patients experiencing less severe alcohol withdrawal (CIWA < 19) who have a history of complicated
alcohol withdrawal symptoms, transfer to a setting with 24-hour medical care should be considered.
B. For patients at risk for alcohol withdrawal (but not presenting signs or symptoms) who have a history of
complicated withdrawal symptoms, more frequent monitoring should be considered.
A-21. Pregnant patients should typically be transferred to a hospital.
A-22. Patients with known or suspected Wernicke encephalopathy and/or suspected Korsakoff syndrome require
immediate administration of parenteral (intravenous or intramuscular) thiamine (vitamin B1) (if unavailable, provide
oral thiamine), as well as benzodiazepines and transfer to a hospital.
A-23. Patients actively seizing as a result of alcohol withdrawal or showing signs of alcohol withdrawal delirium should
be treated immediately with benzodiazepines and transferred to a hospital.
Medications
Long-acting benzodiazepines are the most commonly used medications for treating alcohol withdrawal.21 Dosing
approaches include front loading, fixed, and symptom-triggered (see below). Symptom severity will help determine the
most appropriate dosing regimen, which may be adjusted during the course of treatment. Many jails routinely give one
or two doses of benzodiazepine prophylactically (under protocols, with patient-specific orders) to patients at risk for
alcohol withdrawal as a low-risk, low-cost, effective preventive measure.

Dosage Regimens
Front loading: An approach where moderate to high doses of a long-acting medication are given frequently at the start of treatment to achieve
rapid control of withdrawal signs and symptoms. Front loading can be followed by a symptom-triggered or fixed-dose regimen.
Fixed dosing: An approach where a predetermined dose (which can be determined based on withdrawal severity) is administered at fixed
intervals according to a schedule. Doses usually decrease in a gradual taper over several days. Additional medication may be provided if the
fixed dose does not adequately control symptoms.
Symptom-triggered dosing: An approach where patients are given medication only when symptoms cross a threshold of severity (e.g., 15 mg
oxazepam for CIWA-Ar scores 8–15, 30 mg oxazepam for CIWA-Ar > 15).
WARNING: Symptom-triggered dosing, if used alone, requires highly reliable and dedicated staff to avoid undertreatment of withdrawal and
should be used only when there are adequate qualified staff to perform assessments.
Recommendations
A-24. Benzodiazepines are the preferred agent for treating alcohol withdrawal.
A-25. While no particular benzodiazepine agent is more effective than another, long-acting benzodiazepines are the
preferred agents due to the clinical benefits of their longer duration of action. Adequate treatment with a long-
acting benzodiazepine is effective in preventing withdrawal seizures.
A. See The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management for more detailed clinical
guidance and dosing protocols, including guidance regarding patients with severe liver disease and other
significant comorbidities.
A-26. Patients with CIWA-Ar scores < 10 and who are at minimal risk of developing severe or complicated alcohol
withdrawal may be provided supportive care alone and monitored.
A. It is also appropriate to use benzodiazepines prophylactically for alcohol withdrawal.
A-27. Patients with CIWA-Ar scores > 10 and patients at risk of developing severe or complicated alcohol withdrawal
should receive pharmacotherapy and supportive care.
A-28. Front loading, fixed dosing, and symptom-triggered dosing are all appropriate in jail settings and may be used in
combination.
A-29. Front loading is recommended for patients at risk for severe or complicated alcohol withdrawal (e.g., CIWA-Ar ≥
21). Diazepam and chlordiazepoxide are preferred agents for front loading.
A-30. The patient’s signs and symptoms should be monitored, as discussed in Monitoring Patients During Withdrawal
Management in General Guidance, regardless of the dosing schedule used.
A-31. Qualified health care staff should monitor patients taking benzodiazepines for signs of oversedation and
respiratory depression.
A-32. If a patient’s symptoms are not controlled as expected with the dose of benzodiazepine prescribed, the provider
should consider increasing the dose.
A-33. Benzodiazepines used to treat alcohol withdrawal should be tapered and discontinued following treatment.

A-34. If the patient has been using sedative substances and alcohol, withdrawal should be handled in the same way as
withdrawal from sedatives (see recommendations in Sedative Withdrawal).
A-35. Do not give antiseizure medications prophylactically to prevent alcohol withdrawal unless the patient also has an
underlying seizure disorder.
A-36. Alcohol use disorder (AUD) is a chronic medical condition. Patients should be provided with information about
the range of evidence-based treatments, including medications for AUD, and recovery support services available
in the community.
A. The provider should offer to initiate evidence-based treatment for AUD, including medications and regular
follow-up visits at clinically appropriate intervals. Follow-up visits may include monitoring for return to use,
Motivational Interviewing to encourage engagement in AUD treatment, psychoeducation, and management of
medications for AUD.
A-37. If a patient entering jail is taking prescribed medication for AUD, the medication should be continued unless
otherwise ordered by a prescriber based on documented clinical need.
Supportive Care
Inadequate nutrition associated with heavy alcohol use can lead to conditions that can typically be prevented through
supportive care. For example, thiamine can reduce the risk for Wernicke encephalopathy.
Recommendations
A-38. As discussed in General Guidance, supportive care is appropriate for all levels of alcohol withdrawal severity
and may include nutritional supplementation, IV fluids, glucose, management of electrolyte abnormalities, and
periodic clinical reassessments, as clinically indicated (see Monitoring Patients During Withdrawal Management).
A. If dehydration is an ongoing concern and the jail does not have the capacity to manage IV fluids, the patient
should be transferred to a facility that does.
A-39. Alcohol use can be associated with vitamin and mineral deficiencies.
A. To reduce the risk of encephalopathy, all patients with suspected AUD should be treated with thiamine, 100
mg daily, either orally or intramuscularly for 3–5 days.
B. Other vitamin and mineral supplementation (e.g., magnesium, folate) should be considered, as determined by
the treating provider.

Alcohol withdrawal presents significant risks during pregnancy, often requiring care at a hospital with expertise in
managing high risk obstetrical cases and with fetal monitoring available.
Recommendations
A-40. Pregnant patients should typically be transferred to a setting with 24-hour medical care available (e.g., emergency
department, hospital).

A-41. If managing the patient’s alcohol withdrawal in the jail, consult with a provider experienced in obstetrical care.
A. Specialty consultation should not delay initiation or titration of treatment.
A-42. Benzodiazepines are the preferred medication for treatment of pregnant patients with alcohol withdrawal. While
there is a risk of teratogenicity during the first trimester, the risk appears small and balanced in view of the risk for
FASD and consequences to the mother and fetus should severe maternal alcohol withdrawal develop.
A-43. For patients at risk for preterm delivery or in the late third trimester, use of a short-acting benzodiazepine is
recommended. This minimizes the risk for neonatal benzodiazepine sedation given shorter onset and duration
of action.
A-44. Given the risk of FASD, pregnant patients with alcohol withdrawal should be educated on the importance of
treatment for AUD.
A-45. Pregnant patients should be informed of all wraparound services that will assist them in addressing newborn
needs (including food, shelter, and pediatric clinics for inoculations) and programs that will help with
developmental or physical issues that the newborn may experience as a result of in-utero alcohol exposure.
A-46. Qualified health care professionals should understand and follow their state laws regarding definitions of child
abuse and neglect, reporting requirements, and plans of safe care for newborns with in-utero alcohol exposure.
Managing Comorbidities
Co-occurring medical and psychiatric conditions can complicate the management of alcohol withdrawal and should be
considered when developing the treatment plan.
Recommendations
A-47. For patients with medical comorbidities, consult with specialists as needed to modify the medication and/or
protocol used for treating alcohol withdrawal.
A-48. Hallucinations that develop in the context of alcohol withdrawal may indicate an alcohol-induced psychotic
disorder. A patient who develops hallucinations should be transferred to a higher level of care for treatment.
A. Benzodiazepine medication should be given concurrently with the call for transport, if feasible.
B. Antipsychotic medication can be considered, concurrent with the call for transport, if feasible and needed to
manage severe psychotic symptoms.
A-49. For patients with medical conditions that prevent the use of oral medication, provide IV or intramuscular
medications as necessary.
A. If the jail does not have the capacity to provide medication in these forms, the patient should be transferred to
a higher level of care.

Polysubstance Use Disorder
Benzodiazepines or other sedative medications increase the risk for respiratory depression in patients who are taking
opioids, including methadone or buprenorphine for the treatment of OUD. While the combined use of these medications
increases this risk, the harm caused by untreated opioid withdrawal, OUD, or alcohol withdrawal outweighs these risks.
Consulting with an addiction specialist physician may be helpful in determining an appropriate approach to complex
polysubstance use withdrawal.
Recommendations
A-50. Patients who are taking opioid medication for OUD or pain should be monitored closely when benzodiazepines
are prescribed due to the increased risk of respiratory depression.
A. Patients with concurrent opioid and benzodiazepine withdrawal syndrome should be stabilized on
buprenorphine or methadone and a benzodiazepine, prior to tapering benzodiazepines.
A-51. For patients with co-occurring alcohol withdrawal and OUD, stabilize the OUD (e.g., with methadone or
buprenorphine) concomitantly with alcohol withdrawal management.

Sedative Withdrawal
Sedatives depress the central nervous system. Benzodiazepines are currently the sedative drug most often encountered
in the context of withdrawal risk, but others include barbiturates, GHB, and nonbenzodiazepine hypnotics (Z-drugs).
The following recommendations generally apply to all sedatives, although important differences in the management of
withdrawal from barbiturates and GHB are discussed.
Like alcohol withdrawal, abrupt cessation of prescribed and illicitly used sedatives can result in serious health
consequences and death.22 As noted in G-4, patients entering jails who have been prescribed benzodiazepines or
other sedatives (e.g., gabapentinoids for epilepsy or nerve pain, baclofen for treating muscle stiffness) should continue
receiving the medication unless there is a documented clinical reason for discontinuing the prescription. It is not safe
to abruptly discontinue benzodiazepines or other sedatives prescribed for medical purposes; proper tapering can take
months.23
Screening
Screening for sedative withdrawal risk considers frequency and recency of use, as well as history of complicated sedative
withdrawal. Although barbiturates are becoming less available in the United States due to increased federal controls to
safeguard against dependence and overdose, screening for withdrawal risk remains critical. Barbiturate withdrawal can
be deadly, and patients should be treated in a hospital setting (see SH-9).
Recommendations
SH-1. Individuals who report recent, regular use of sedatives (daily or near daily use and use within the past 7 days)
should be referred for immediate clinical assessment. [Note that this does not apply to use of prescription
sedatives taken as prescribed, as the patient should have continued access to the medication.]
SH-2. Individuals reporting any past-week use of sedatives and a history of complicated sedative withdrawal (e.g.,
seizures, psychosis, hallucinations) should be referred for immediate clinical assessment.

Individuals reporting less regular (i.e., less than daily or near daily) use of sedatives should also be monitored for
signs and symptoms of withdrawal. Since different sedatives vary in the length of time they are active in the body,
the appearance of withdrawal may vary (table SH-1). Short-acting benzodiazepines are processed and leave the
body quickly, which leads to a higher risk of withdrawal symptoms developing sooner and escalating quickly. Long-
acting benzodiazepines are processed more slowly by the body; therefore, withdrawal symptoms may emerge over a
longer period.

Table SH-1: Development of Sedative Withdrawal Symptoms
Duration of Action Examples Timeframe
Short-acting alprazolam, lorazepam First 24 hours after cessation of use
Long-acting clonazepam, diazepam 24–48 hours after cessation of use
Some indicators of sedative withdrawal (table SH-2) may be misattributed to other causes, highlighting the importance of
referring any individual who appears unwell for immediate clinical assessment.
Table SH-2: Possible Indicators of Sedative Withdrawal*24,25,26

• Abdominal cramping, nausea, and vomiting • Insomnia
• Anxiety • Occasional psychotic thoughts
• Circulatory failure • Restlessness
• Delirium (including disorientation and hallucinations) • Seizures
• Hyperthermia and sweating • Tremors
• Increased heart rate and blood pressure • Unease
*Staff should be alert to any indicators that the individual is unwell, not only those listed here.
Recommendations
SH-3. Individuals who self-report risk for sedative withdrawal and those who report sedative use below the threshold
specified in SH-1 (daily or near daily and within past 7 days) should be monitored at least every 6 hours for at least
the first week for emergence of withdrawal signs and symptoms.
SH-4. Although a few benzodiazepine withdrawal scales have been developed, there is no single scale that has been
well validated and replicated. As discussed in General Guidance, if signs or symptoms emerge or if the individual
begins to appear unwell to a layperson, they should be referred for immediate clinical assessment.

All sedative withdrawal should be treated, regardless of length of jail stay. Clinical assessment will determine the type
and intensity of care required to address the patient’s needs.
No validated scales for assessing sedative withdrawal exist. The Clinical Institute Withdrawal Assessment Scale –
Benzodiazepines (CIWA-B) is a 22-item instrument for assessing and monitoring symptoms of benzodiazepine
withdrawal, but its validity and reliability have not been fully determined.27
Recommendations
SH-5. As with all withdrawal, a patient history and physical exam including vital signs should be done to assess
withdrawal severity and inform treatment.
SH-6. Do not use the CIWA-Ar for assessing sedative withdrawal.
SH-7. Because of the high risk of delirium, seizures, and death, sedative withdrawal should always be treated.

Level of Care
Withdrawal from barbiturates and GHB is complex and requires hospital-level care, as does severe or complicated
withdrawal from benzodiazepines. Patients should be transferred to a hospital, preferably (when possible) a hospital with
expertise in treating sedative withdrawal. Use of GHB is typically determined by patient history due to its short-acting
nature. If the patient is intoxicated, obtaining this history may be difficult; however, witnesses (law enforcement, family,
friends) may be able to provide information about GHB use.
Recommendations
SH-8. For sedative withdrawal, hospitalization is suggested for patients showing signs of severe or complicated withdrawal.
A. These signs may include:
i) Delirium.
ii) Hallucinations.
iii) Changes in consciousness.
iv) Profound agitation.
v) Autonomic instability (when heart rate, blood pressure, and sweating and other nonvoluntary body
functions fluctuate).
vi) Seizures.
B. For patients experiencing less severe sedative withdrawal who have a history of complicated sedative
withdrawal symptoms, transfer to a setting with 24-hour medical care should be considered.
C. For patients at risk for sedative withdrawal (but not presenting with signs or symptoms) who have a history of
complicated withdrawal symptoms, more frequent monitoring should be considered.
SH-9. Hospitalization is recommended for patients experiencing barbiturate withdrawal, unless the jail has hospital-level
capacity (i.e., telemetry [including cardiac monitoring] and full-code response including intubation/ventilation support).
SH-10. GHB withdrawal is complex and technically more difficult than other sedative withdrawal. Transfer to a hospital is
recommended. When possible, the patient should be transferred to a hospital with experience treating complex
sedative withdrawal.

Recommendations
SH-11. Patients treated for sedative withdrawal should have a daily clinical assessment by a qualified health care
professional for at least the first week, or as their condition indicates.
A. After the first week, patients should be assessed by a qualified health care professional at least two times per
week until the taper is complete (see SH-14).

Medications
For most patients, treatment for benzodiazepine withdrawal involves pharmacotherapy with a long-acting
benzodiazepine to stabilize withdrawal symptoms before slowly tapering by 10–25 percent per week. It is important
that tapering be no more rapid than 25 percent per week. In circumstances where initial tapering requires unusually
high doses of benzodiazepines, providers may consider transferring the patient to a hospital with expertise in
sedative withdrawal.
Tapers extending beyond the time of custody will require a prescription for the long-acting benzodiazepine initiated for
tapering, as well as linkage to ongoing care at the time of release.
Recommendations
SH-12. Treatment should not be delayed based on the potential timeline for release.
SH-13. Patients who have been taking sedatives should be converted to an equivalent dose of long-acting
benzodiazepine.
A. Clonazepam has a long half-life and is well-tolerated and easy to administer. It is the preferred medication for
treatment of benzodiazepine withdrawal for most patients.
B. Individuals metabolize clonazepam at different rates; therefore, the dose equivalencies will not hold for all
patients and must be individualized according to the patient’s response. Adequate dosing of clonazepam will
control sedative withdrawal symptoms, including increased heart rate, sweating, and hand tremor.
SH-14. Benzodiazepines should be tapered over a period of weeks or months. Taper duration should be based on the
patient’s agent of choice, dose, frequency and duration of use, comorbid physical or mental health conditions,
and treatment setting.
A. In patients who are not hospitalized, the medication should not be tapered any more rapidly than 25 percent
per week.
B. As the taper nears the end, it may be necessary to taper more slowly if anxiety or insomnia develop. These
symptoms can continue for many months.
C. Comorbid conditions should be monitored throughout withdrawal to inform the taper schedule.
SH-15. If withdrawal symptoms increase, medication dosage should be stabilized or even increased for a period of days.
SH-16. Signs and symptoms of sedative withdrawal (e.g., insomnia and anxiety) may last beyond the period of acute
withdrawal. These symptoms may take months or years to resolve and should be treated with evidence-based
interventions.
SH-17. If the patient is experiencing both sedative and opioid withdrawal, provide methadone or buprenorphine to
stabilize withdrawal from opioids before tapering the dose of the sedative.
SH-18. If the patient has been using multiple sedative substances or a sedative and alcohol, withdrawal should be
handled by using an equivalent or longer-acting agent than the longest-acting agent used by the patient.

SH-19. Do not give antiseizure medications prophylactically to prevent sedative withdrawal unless the patient also has an
underlying seizure disorder.
Supportive Care
Sedative withdrawal can cause a number of side effects, including insomnia and anxiety, that may be relieved through
supportive care (when possible).
Recommendations
SH-20. In addition to the recommendations in General Guidance, supportive care for patients in sedative withdrawal may
include cognitive behavioral therapy (except during acute withdrawal), stress management, sleep hygiene, and
relaxation training, which may be helpful both during and after taper.

Treating sedative withdrawal can be safely managed in pregnancy, following the guidelines described above.
Recommendations
SH-21. Pregnant patients should undergo withdrawal management slowly and in consultation with an obstetrician.
SH-22. The principles of withdrawal management from sedatives are the same for pregnant and non-pregnant patients.

Opioid Withdrawal
Opioids include illicit drugs (e.g., heroin, illicitly manufactured fentanyl, and its analogues) and prescription pain relievers,
such as oxycodone (Percocet or Oxycontin), hydrocodone (Vicodin), methadone, and morphine. Individuals who are
physiologically dependent on opioids, including those who regularly use either illicit or prescription opioids, are at risk
for opioid withdrawal.
Dangerous Changes in Drug Composition

Individuals may not always know that they have been using opioids or which opioids they have been using. Increasingly, individuals are
consuming counterfeit pills or drugs containing fentanyl.28,29 Given the high potency of fentanyl mixed in with the drug supply, multiple doses of
naloxone may be necessary to reverse an overdose.30
It is important for qualified health care professionals to understand the regional drug supply, remain current on clinical guidance, and regularly
revisit response protocols. For example, the veterinary tranquilizer xylazine, which is currently added to fentanyl and other illicit opioids, has been
linked to many overdose deaths in the Northeast. Naloxone may be less effective in cases of overdoses involving opioids mixed with xylazine.31
Opioid withdrawal syndrome can be medically complex and, in the absence of appropriate management, life-
threatening. For example, vomiting and diarrhea associated with opioid withdrawal can lead to electrolyte imbalances
and cardiac arrythmias, and the high blood pressure and rapid pulse characteristic of opioid withdrawal can exacerbate
underlying cardiac illness. Monitoring for and treating opioid withdrawal can prevent serious health outcomes,
including death.
Many jails currently subject individuals to opioid withdrawal by either not offering buprenorphine or methadone
treatment or not initiating it in a timely manner, such that individuals are subject to withdrawal before treatment is
initiated or they are released. These practices put individuals at significant medical risk during their stay in jail and
increase likelihood of overdose if they resume opioid use upon return to the community, due to reduced tolerance. In
addition, as discussed in The ASAM National Practice Guideline [NPG] for the Treatment of Opioid Use Disorder [OUD],
“opioid withdrawal management on its own, without ongoing pharmacotherapy, is not a treatment method for opioid
use disorder and is not recommended.”32
For these reasons, it is recommended that individuals with OUD who are at risk for opioid withdrawal be offered
initiation of long-term pharmacotherapy for OUD, which should be initiated in a timely manner as discussed in the
recommendations below. If the patient declines long-term treatment with medication for OUD or prefers to initiate
naltrexone to prevent return to use, the patient should be offered buprenorphine or methadone treatment to treat
opioid withdrawal.
Screening
As discussed in General Guidance, all individuals should be screened for recent substance use using a validated
screening tool and asked if they are at risk for opioid withdrawal.

Recommendation
O-1. Anyone who reports regular use of opioids (including prescription opioid misuse), OUD, or opioid withdrawal risk
should be considered at risk for opioid withdrawal. [Note that this does not apply to use of prescription opioids
taken as prescribed, as the patient should have continued access to the medication.]
A. If prescription opioids are discontinued, based on a patient-specific order from a provider (see G-4), the
patient should be considered at risk for opioid withdrawal.

Opioid withdrawal syndrome refers to the wide range of symptoms that occur when individuals who regularly take
opioids, either illicit or prescribed, stop or reduce their use. Regular monitoring for signs and symptoms of withdrawal
supports rapid identification and referral for clinical assessment.
Some individuals may initially screen negative for withdrawal risk but later exhibit signs or symptoms of withdrawal
(tables O-1 and O-2). Custody staff should be well-trained to refer all individuals who appear unwell for immediate
clinical assessment (see G-44), regardless of initial screening results.
Table O-1: Opioid Withdrawal Symptom Emergence and Duration33

Emergence Duration
Short-acting opioids (e.g., heroin, oxycodone) Within 12 hours of last use and peaking within 3–5 days
24–48 hours
Long-acting opioids (e.g., methadone) Within 30 hours of last use Up to 10 days
Table O-2: Possible Indicators of Opioid Withdrawal*34

• Agitation • Muscle aches
• Anxiety • Nausea
• Abdominal cramping • Piloerection (“goose bumps”)
• Diarrhea • Runny nose
• Dilated pupils • Sweating
• Increased tearing • Vomiting
• Insomnia • Yawning
* Staff should be alert to any indicators that the individual is unwell, not only those listed here.
Recommendations
O-2. Individuals may be considered at risk for opioid withdrawal even if they do not meet the clinical criteria for
an OUD.
O-3. Individuals who report regular opioid use (including prescription opioid misuse) or screen positive for current
OUD should be monitored for signs and symptoms of opioid withdrawal at least every 4 hours for the first 72
hours of incarceration.
A. As discussed in General Guidance, individuals at risk for withdrawal should ideally be housed together in a
dedicated unit to facilitate monitoring.
B. Patients who appear unwell to a layperson or score ≥ 3 on the COWS should be referred for immediate clinical
assessment.

The initial clinical assessment, conducted by a qualified health care professional, focuses on identifying any medical
risks that would necessitate a higher level of care or a full medical evaluation. Validated assessment tools, such as
the COWS, allow for methodical collection of information about withdrawal signs and symptoms at assessment and
during monitoring.
Recommendations
O-4. The initial clinical assessment should focus on identifying signs and symptoms of opioid withdrawal, as well as
overdose and withdrawal risk.
A. Assessment of withdrawal risk should focus on the types of opioids used, route of use, length of time used,
symptoms when use has stopped or decreased, and details of last use (when, how much, and what type).
O-5. If a patient treated with buprenorphine or methadone for presumed opioid withdrawal does not respond to
treatment, the qualified health care professional should consider whether the dose needs to be increased or if the
patient may have been misdiagnosed.
A. Differential diagnosis should include serious illnesses that can mimic the signs and symptoms of opioid
withdrawal including withdrawal from other substances, myocardial infarction, pulmonary embolus, respiratory
infection, severe abdominal infection, diabetic ketoacidosis, sepsis, and thyrotoxicosis, among others.
Medications
Initiating ongoing treatment for OUD with buprenorphine or methadone will prevent severe opioid withdrawal, as well
as alleviate cravings that can result in return to use, overdose, and overdose death when patients regain access to
opioids. To establish reliable access to medication, jails should have formal relationships with providers of methadone
and buprenorphine treatment. Regarding the latter, the Substance Abuse and Mental Health Services Administration
(SAMHSA) states, “All practitioners who have a current [Drug Enforcement administration (DEA)] registration that
includes Schedule III authority may now prescribe buprenorphine for opioid use disorder in their practice if permitted
by applicable state law.”35 Mobile narcotic treatment programs registered with the DEA are allowed to operate at
correctional facilities when doing so does not conflict with applicable federal, state, tribal, or local laws and regulations;36
such programs may expand jail capacity for offering medications. Local public health authorities and state substance use
treatment authorities should be able to provide guidance to support jails that lack expertise in this area.
Jail administrators are encouraged to consider barriers to accessing buprenorphine and methadone in the community.
If there are no methadone treatment providers, patients will be unable to continue methadone treatment, in which case
buprenorphine may be the preferred option. For more information on reentry, go to General Guidance.
It is important that the patient’s treatment plan, including choice of medication for OUD management and need for
psychosocial treatment, be based on individual clinical needs and informed choice and not policy decisions that
disincentivize medications for OUD.

WARNING
• Concurrent use of methadone or buprenorphine with alcohol or benzodiazepines increases respiratory depression risk. However, concurrent
treatment with benzodiazepines (e.g., for co-occurring alcohol or sedative withdrawal) should not be a reason to withhold treatment with
buprenorphine or methadone. Increased monitoring may be appropriate.
• Naltrexone is not approved by the FDA for withdrawal management purposes and does not relieve withdrawal symptoms. It cannot be
administered until patients are free of short-acting opioids for at least 7–10 days or 10–14 days for long-acting opioids. Failing to observe
these wait periods may cause precipitated withdrawal.
• Anesthesia-assisted opioid detoxification or ultra-rapid opioid detoxification, which involves large doses of naloxone, anesthesia, and a
diuretic, has been associated with serious complications (including cardiac arrest and death) and is not recommended.
Recommendations
O-6. Buprenorphine and methadone are first-line treatments for opioid withdrawal and OUD.
A. All patients at risk for opioid withdrawal should have rapid access to treatment with these medications.
O-7. Because opioid withdrawal management without ongoing OUD treatment increases the risk for overdose and
overdose death, the appropriate clinical strategy is to prevent opioid withdrawal by initiating ongoing treatment
for OUD with buprenorphine or methadone.
O-8. Naltrexone is not a treatment for opioid withdrawal. Extended-release naltrexone is a treatment option for OUD
in patients who are no longer physiologically dependent on opioids. However, this medication will exacerbate
withdrawal in patients who are dependent on opioids.
O-9. Initiation of medications should not be delayed in patients experiencing or at risk for opioid withdrawal. As noted
in General Guidance, completion of the full assessment is NOT required before initiating medication for opioid
withdrawal or OUD.
O-10. Once the diagnosis of OUD or opioid withdrawal is confirmed, treatment should be initiated immediately, without
regard for the expected duration of incarceration.
O-11. All jails should have a plan for providing same-day access (or access within 24 hours of entry) to buprenorphine
and methadone.
O-12. With the expansion of eligibility to prescribe buprenorphine, all jails should be able to provide access to
buprenorphine treatment. However, jails lacking the capacity to manage opioid withdrawal with buprenorphine or
methadone should have protocols in place to ensure that patients experiencing opioid withdrawal can be rapidly
transferred to an appropriate treatment setting that can provide one of these medications.
O-13. Polysubstance use is not a contraindication for treating opioid withdrawal or OUD with medication.
A. Urine drug screen results should not be used to deny patients access to medications for opioid withdrawal
or OUD.
O-14. The use of benzodiazepines and other sedatives should not be a reason to withhold or suspend treatment with
methadone or buprenorphine. While the combined use of these medications increases the risk of serious side
effects, the harm caused by untreated OUD can outweigh these risks. A risk-benefit analysis should be conducted,
and greater support should be provided, including careful medication management to reduce risks.

O-15. If individuals entering jail are experiencing symptoms of moderate to severe opioid withdrawal, they should
be referred for immediate clinical assessment by a provider who can initiate buprenorphine or methadone or
transferred to a facility that can provide buprenorphine or methadone if indicated.
O-16. Even if the patient may not be able to maintain treatment in the community, buprenorphine or methadone should
still be initiated.
O-17. Patients undergoing withdrawal management should be advised of the risk of returning to use, overdose, and
overdose death if they choose not to engage in ongoing medication treatment.
O-18. Jails that do not have prescribers onsite 24 hours per day, 7 days per week should consider using telehealth to
support access to buprenorphine and methadone treatment.
O-19. Opioid withdrawal management is not necessary if the patient is immediately initiated on methadone or
buprenorphine upon intake to the jail. However, if opioid withdrawal management is clinically indicated
or if the patient declines ongoing treatment with medications for OUD, buprenorphine or methadone
are also recommended for withdrawal management (see The ASAM NPG for the Treatment of OUD for
tapering guidance).
O-20. For protocols for initiating medications for OUD, refer to The ASAM NPG for the Treatment of OUD.
O-21. Jails should establish mechanisms for rapidly initiating methadone or buprenorphine treatment when the provider
is off-site.
O-22. Adjunctive medications (e.g., clonidine, anti-nausea medication) should not be necessary if buprenorphine or
methadone is provided in adequate doses (typically ≥ 16 mg/day of buprenorphine; see The ASAM NPG for the
Treatment of OUD for methadone-dosing recommendations) and should not be used in the place of an adequate
dosage of buprenorphine or methadone.
A. Patient discomfort during opioid withdrawal management may indicate the dose of buprenorphine or
methadone is too low.
O-23. Policy decisions disallowing or disincentivizing FDA-approved medications for opioid withdrawal or OUD are not
clinically appropriate.
O-24. Jails should consider offering psychosocial treatment to patients with OUD (based on an assessment of their
psychosocial needs), in addition to pharmacotherapy. However, a patient’s decision to decline psychosocial
treatment or the absence of available psychosocial treatment should not preclude or delay pharmacological
treatment.
O-25. Patients entering the jail who take prescribed opioid medications for chronic pain treatment should be permitted
to continue these medications. (See also G-4 and supporting narrative.)
A. If a provider determines and documents that continuation of opioid analgesic medications is clinically
inappropriate, the medication should be tapered slowly according to current clinical guidelines (see guidance
from the U.S. Department of Health and Human Services), and the patient should be monitored for signs and
symptoms of withdrawal.

Buprenorphine
Buprenorphine is an effective medication for treating both opioid withdrawal and OUD. Recent changes in federal
legislation allow buprenorphine to be prescribed by any prescriber with a DEA registration to prescribe controlled
substances. However, some states may limit buprenorphine-prescribing authority.
Buprenorphine should be initiated when the patient shows objective signs or symptoms of withdrawal (e.g., pupil
dilation, goose bumps, gastrointestinal discomfort). In a patient at risk for opioid withdrawal, if buprenorphine is
initiated (using standard protocols) before the patient is showing signs of withdrawal, the patient may experience
precipitated withdrawal, resulting in a higher COWS score, and severe symptoms, such as vomiting and diarrhea.
As determined by clinical consensus in the absence of data, the patient should be monitored by a qualified health
care professional for at least 30 minutes after the initial administration of buprenorphine, as precipitated withdrawal
will require immediate treatment and may require a higher level of care. Due to the rapid pace at which clinical
practice is changing, jails should collaborate closely with community providers and hospitals on evolving protocols for
buprenorphine initiation (including low dose initiation protocols).37
The COWS assessment can be helpful in determining if patients are experiencing mild to moderate withdrawal. In
community settings, a score of 11–12 is typically indicative of sufficient withdrawal to initiate buprenorphine. However,
the EC has observed underscoring of the COWS in jail settings such that some jails initiate buprenorphine with a
COWS score of 6 or more. Use of COWS will be more effective when jails periodically evaluate how often patients are
experiencing significant withdrawal signs/symptoms (e.g., vomiting or diarrhea) and how often patients are experiencing
precipitated withdrawal, adjusting threshold protocols accordingly. If patients are experiencing significant withdrawal
before buprenorphine is initiated, initiation should be triggered by a lower COWS score. If the initiation protocols are
leading to precipitated withdrawal, initiation should be triggered by a higher COWS score.
The ASAM NPG for the Treatment of OUD provides recommendations for standard dosing protocols. Recent studies
have reported successful buprenorphine initiation using alternative dosing protocols including micro-dosing strategies
and high-dose buprenorphine initiation, which may be considered (see Resources). For administration during
incarceration (and assuming administration is monitored by custody staff), any buprenorphine formulation may be
considered.
Table O-3: Buprenorphine Formulations38

Name Route of For the Treatment of Comments
Administration (Dosing)
For all formulations:
• Titration is advised during the first 1–3 weeks of treatment.

• Standing orders for dose initiation are not advised.
Generic: Buprenorphine Sublingual tablets (daily) Opioid withdrawal and OUD. While there is a higher risk for misuse of
the buprenorphine-only product in the
Brand: Generic versions community, that risk may be lower in the
available similar to Subutex jail because administration is observed.
Generic: Buprenorphine and Sublingual tablets and film Opioid withdrawal and OUD.
naloxone (daily)
Brand: Generic versions

available in addition to
Suboxone, Cassipa, Zubsolv

Table O-3: Buprenorphine Formulations (continued)
Generic: Buprenorphine Extended-release injection Moderate to severe OUD in patients • No risk for patient diversion or misuse.
extended-release (monthly) who have initiated treatment with • Requires patients to be on a stable
transmucosal forms, followed by dose dose of transmucosal buprenorphine
Brand: Sublocade adjustment for a minimum of 7 days. for at least 7 days.
• Less fluctuation in buprenorphine
levels (compared to daily doses).
Generic: Buprenorphine Extended-release injection Moderate to severe OUD in patients • No risk for patient diversion or misuse.
extended-release (weekly or monthly) after a single dose of transmucosal • Only a single prior dose of
buprenorphine or who are already transmucosal buprenorphine required
Brand: Brixadi being treated with buprenorphine. prior to initiation.
• Less fluctuation in buprenorphine
levels (compared to daily doses).
Recommendation
O-26. Buprenorphine should be initiated when the patient shows objective signs of opioid withdrawal.
A. The patient should be monitored for precipitated withdrawal for at least 30 minutes after the initial
administration of buprenorphine.c
B. If a patient is experiencing precipitated withdrawal and a prescriber is not immediately available to conduct an
assessment, the patient should be transferred to a hospital.
Methadone
Methadone, a long-acting full opioid agonist, is an effective treatment for opioid withdrawal syndrome and OUD. With
the exception of access under the 72-hour emergency rule, methadone for the treatment of OUD is currently only
available through federally registered opioid treatment programs (OTPs).
72-Hour Emergency Rule

Under this rule, a physician outside of an OTP is allowed to administer (but not prescribe) methadone to a patient to relieve acute withdrawal
symptoms while arranging for the patient’s referral for treatment, for up to 72 hours. This may not be renewed or extended, nor may more than
1 day’s medication may be administered or given to a patient at one time.39
Jails can either become a certified OTP40 or establish an MOU with an external methadone treatment provider detailing
roles, responsibilities, payment, and security concerns, such as:
• Transport of patients to the methadone treatment provider.
• Transport of methadone to the jail by methadone treatment provider, jail medical, or jail custody staff.
• Guest dosing for patients who are established with a different methadone treatment provider.
As noted above, properly registered mobile narcotic treatment providers provide another treatment option for
correctional facilities, which may be especially useful in rural communities.
c
Note: Buprenorphine may be initiated prior to the emergence of objective signs of withdrawal when using a low-dose buprenorphine initiation
protocol. See ASAM’s “Treatment of Opioid Use Disorder with Buprenorphine: Clinical Consideration for Treatment of Individuals with OUD using High
Potency Opioids” (submitted March 23).

Methadone can be difficult to access, and discontinuation of this medication puts the patient at risk of returning to use,
so reentry planning upon initiation of methadone is essential.
Table O-4: Methadone Formulations41

Generic: Methadone • Liquid concentrate, Opioid withdrawal and OUD • Federal law mandates that the initial
tablet, oral solution of dose cannot exceed 30 mg, and the
Brand: Methadose, Dolophine powder, or dispersible total dosage on the first day cannot
tablet (daily). exceed 40 mg.
• Injection for temporary • Methadone may cause respiratory
treatment of opioid depression, particularly during
dependence in patients initial dosing.
unable to take oral • Titration is advised during the first
medication.42 1–3 weeks of treatment.
• Standing orders for dose initiation are
not advised.
Recommendations
O-27. Jails should consider obtaining certification from SAMHSA to administer and dispense methadone or partnering
with a local methadone treatment provider to provide access to methadone and support seamless transitions of
care on entry and release.
O-28. Methadone treatment must be managed by a methadone treatment provider, except when using the 72-hour
emergency prescribing authority. The dose (or taper schedule when clinically indicated or preferred by the
patient) should be determined by the methadone treatment provider, not by custody staff or policies.
O-29. If using methadone to treat OUD or opioid withdrawal, follow The ASAM NPG for the Treatment of OUD for
medication initiation and dosages.
O-30. Patients do not need to experience withdrawal symptoms before methadone treatment is initiated.
Treating Patients Currently Receiving Buprenorphine or Methadone

As explained in The Americans with Disabilities Act and the Opioid Crisis: Combating Discrimination Against People
in Treatment or Recovery, patients in treatment for OUD who are not engaging in illegal drug use, including those who
are prescribed medication to treat their OUD, are protected from discrimination. By law, patients meeting these criteria
who enter jail should be allowed to continue medications for SUD treatment in consultation with clinical providers.43
Furthermore, continuation of treatment while incarcerated lowers the odds of reincarceration and increases the odds of
remaining in treatment.44 Methadone withdrawal in particular is a painful experience, and the fear of experiencing this
again can make patients reluctant to restart the medication.45
Partnerships between jails and a methadone treatment provider in the region can facilitate continued access to
methadone for patients who were in methadone treatment prior to incarceration.
It may be necessary or appropriate for patients to transition from one OUD medication to another, such as when they
cannot tolerate side effects. The transition from methadone to buprenorphine can be medically complex because of
the long duration of action of methadone and the risk for precipitated withdrawal. (Transitioning from buprenorphine to
methadone does not pose a risk of precipitated withdrawal.) In the rare instances where discontinuation of methadone
or buprenorphine is clinically indicated, the complexity of discontinuation requires the services of a medical provider with
SUD treatment expertise (board certified or with 2 or more years of experience in specialty SUD treatment).

Recommendations
O-31. It is not appropriate to require a change in or discontinuation of OUD medication for nonclinical reasons (e.g.,
conditions of custody, release).
O-32. Discontinuing OUD medication puts the individual at risk for opioid withdrawal, and increases the risk for
returning to use, overdose, and overdose death. Jails should continue treatment for patients who, upon arrival,
are taking medication for treatment for OUD. (See also recommendation statement G-4 and supporting narrative.)
O-33. Patients should not be required to transition from opioid agonist (methadone or buprenorphine) to opioid
antagonist (naltrexone) treatment.
O-34. In the absence of a methadone treatment provider or a provider authorized to prescribe buprenorphine (in states
that restrict buprenorphine prescribing), jails should use the 72-hour emergency prescribing authority to provide
methadone or state emergency access provisions to provide buprenorphine while they make arrangements for
ongoing treatment.
A. The 72-hour emergency prescribing authority (and, typically, other emergency access provisions) cannot
be renewed during the individual’s stay in jail and should not be used in place of establishing access to
buprenorphine and methadone.
O-35. Transitioning patients currently in methadone treatment to buprenorphine is clinically complex and should be
managed by, or in consultation with, a provider experienced in managing this transition.
O-36. Discontinuation of methadone or buprenorphine is clinically complex and should be done only when clinically
indicated and by a medical provider with SUD treatment expertise.
O-37. Tapering methadone takes longer in patients who are in methadone treatment compared to those initiated
on methadone to treat withdrawal. Jails should not attempt to manage this process without the oversight of a
methadone treatment provider.
Alpha-2 Adrenergic Agonists (Second-line Treatment)

Alpha-2 adrenergic agonists (FDA-approved lofexidine and off-label use of clonidine) can be used to treat withdrawal
when patients choose to taper off buprenorphine or methadone, and in preparation for initiation of extended-release
naltrexone. These medications are a second-line option, because they do not relieve opioid withdrawal symptoms as
effectively as buprenorphine and methadone and can cause low blood pressure. This risk is increased when patients
are not adequately hydrated. In addition, there can be dangerous elevations in blood pressure when this medication
is stopped in patients with existing hypertension. When used, these medications are often combined with other
medications targeting specific opioid withdrawal symptoms, such as benzodiazepines for anxiety, loperamide or
bismuth salicylate for diarrhea, acetaminophen or nonsteroidal anti-inflammatory medications (NSAIDs) for pain, various
medications for insomnia, and ondansetron for nausea.
Recommendations
O-38. Lofexidine or clonidine may also be appropriate to manage opioid withdrawal in the rare situations where
complete opioid withdrawal management is clinically indicated, including when the patient declines treatment
with buprenorphine or methadone.

A. Alpha-2 adrenergic agonists are contraindicated in patients with low blood pressure. As these medications can
cause hypotension, blood pressure should be monitored regularly in patients prescribed these medications by
personnel well-trained in blood pressure measurement.
B. See The ASAM NPG for the Treatment of OUD and SAMHSA’s Medication-Assisted Treatment for
Opioid Addiction in Opioid Treatment Programs, Treatment Improvement Protocol (TIP) 43) for dosage
recommendations.
Level of Care
As discussed in General Guidance, the level of care should be appropriate for the anticipated severity of the withdrawal
syndrome, as well as any medical or psychiatric comorbidities present. Where treatment services and resources are
recommended in this section, including buprenorphine and methadone treatment, and are not immediately available in
the jail, timely transfer to a higher level of care is indicated.

The withdrawal severity score should gradually decrease following medication initiation. An increasing score following
buprenorphine initiation may indicate precipitated withdrawal and should trigger an immediate medical assessment. As
mentioned in G-33, monitoring should only be discontinued upon a patient-specific order from the prescriber based on
clinical evaluation and determination that it is safe to do so.
Recommendations
O-39. Opioid withdrawal symptom severity should be monitored with a validated tool, such as the COWS.
O-40. To support management of opioid use, it is recommended that jails, at minimum, have:
A. Staff who are well-trained to administer the COWS (or another validated tool) available at all times.
B. A provider authorized to prescribe buprenorphine on staff, under contract, or under a memorandum of

understanding.
C. When feasible, direct affiliation with a methadone treatment provider to provide access to methadone.
O-41. Custody staff may be trained to effectively administer the COWS, including collection of vital signs.
O-42. The onset and severity of opioid withdrawal is dependent on the type of drug taken, when it was last taken,
and how long it lasts in the person’s body. Monitoring intervals should be determined by a qualified health care
professional based on the anticipated timing and severity of withdrawal for the individual patient.
A. Patients who report use of a short-acting opioid (e.g., heroin, oxycodone, fentanyl) should be monitored using
the COWS at least every 4 hours.
B. Patients who report using long-acting opioids (e.g., extended-release formulations, methadone) should be
monitored using the COWS at least every 8 hours.
O-43. In patients with concurrent sedative use disorder or withdrawal, methadone or buprenorphine should be used to
stabilize withdrawal from opioids.

A. Once opioid withdrawal is stabilized, it is appropriate to begin tapering the dose of the sedative as discussed
in Sedative Withdrawal.
O-44. Concurrent stimulant use disorder is not a reason to delay or deny medication for OUD or opioid withdrawal.
The patient should be offered evidence-based psychosocial treatment for the stimulant use disorder. However, if
psychosocial treatment is not available or the patient declines, this should not preclude or delay pharmacological
treatment of OUD or opioid withdrawal.
O-45. Treatment for opioid withdrawal or OUD should not be delayed in patients with comorbid mental illness (e.g.,
depression, anxiety, psychosis).
A. Withdrawal can exacerbate symptoms of depression and anxiety, and treatment of opioid withdrawal or OUD
with medication can often improve these symptoms. The patient’s mental health should be reassessed once
they are on a stable dose of medication or after they are no longer in withdrawal.
Supportive Care
Recommendations
O-46. In addition to the items discussed in Supportive Care in General Guidance, patients treated for opioid withdrawal
or OUD should be educated on:
A. The risk of overdose after withdrawal and strategies to mitigate the risk.
B. The effectiveness of medications for treating OUD and reducing overdose risk.
O-47. Vomiting or diarrhea may indicate opioid withdrawal has not been adequately treated (e.g., the dose of
buprenorphine or methadone is too low) and the patient may be at risk of dehydration. The provider should be
alerted if vomiting, diarrhea, or indicators of dehydration arise.
A. If inadequate opioid withdrawal treatment is suspected, the provider should consider increasing the dose of
medication while managing the risk for dehydration.
B. If the jail does not have the capacity to safely and effectively manage fluid loss and replacement in a patient
with vomiting and/or diarrhea, the patient should be transferred to a facility that does.

Opioid misuse in pregnancy is associated with several complications (including preeclampsia, miscarriage, premature
delivery, fetal growth restriction, and fetal death),46 many of which can be ameliorated with prenatal care and medication
for OUD. It is difficult to establish the extent to which these problems are due to opioid use, withdrawal, or co-occurring
use of other drugs. Opioid withdrawal, without ongoing medication treatment, during pregnancy and the postpartum
period is also associated with high return-to-use rates and associated risk for overdose and overdose death.47
The standard of care for pregnant and postpartum patients with OUD is ongoing treatment with buprenorphine
or methadone. Barring other medical contraindications, breastfeeding is safe for people receiving methadone or
buprenorphine for OUD and provides important maternal and fetal benefits, especially for infants born to women
receiving this medication.48

Recommendations
O-48. Psychosocial treatment alone or withdrawal management alone are not appropriate for pregnant or postpartum
patients with OUD. Pregnant and postpartum patients who are physically dependent on opioids should receive
ongoing treatment with methadone or buprenorphine to prevent harm to the patient and fetus.
O-49. Methadone or buprenorphine treatment should be initiated as early as possible during pregnancy since opioid
withdrawal can increase the risk of miscarriage or premature delivery.
A. Transfer to the hospital is likely to be needed for appropriate management, especially in the third trimester of
pregnancy.
O-50. Opioid withdrawal risk in pregnant patients should be treated with urgency. If the jail does not have the capacity
to initiate methadone or buprenorphine, the patient should be immediately transferred to a health care facility
with this capacity.
O-51. Care for pregnant patients at risk for opioid withdrawal should be managed by providers experienced in
obstetrical care and the treatment of OUD. If the jail does not have obstetric capabilities or expertise, they should
consult with an obstetrical care provider or transfer the patient to a facility with this expertise.
A. Specialty consultation should not delay initiation or titration of treatment.
O-52. Pregnant patients should be counseled on the clear evidence of safety and efficacy of buprenorphine and
methadone for preventing opioid withdrawal and treating OUD during pregnancy. These medications are the
safest treatment options for the pregnant patient and the fetus.
O-53. All staff should be educated on the clear evidence of safety and efficacy of buprenorphine and methadone for
preventing opioid withdrawal and treating OUD during pregnancy.
O-54. Qualified health care professionals should be aware that the pharmacokinetics of buprenorphine and methadone
are affected by pregnancy. With advancing gestational age, plasma levels of these medications progressively
decrease and clearance increases. Beginning in the second trimester, pregnant patients should be regularly
evaluated for responses to these medications and encouraged to alert the medical team if cravings or signs and
symptoms of withdrawal emerge. Increased and/or split doses should be offered when clinically indicated.
O-55. After the pregnancy has ended, the patient should continue with medications for SUD treatment. Doses may
need to be reduced if there is evidence of oversedation, with consideration of patient input.
O-56. Engagement and retention in methadone or buprenorphine treatment should be supported. There should be no
punitive consequences to engagement in methadone or buprenorphine treatment.
A. Treatment with medication should never increase the patient’s risk for losing custody of their children,
prevent access to drug court, or compromise release.
O-57. Jails should establish linkages with community programs to ensure smooth transitions of care for patients with
OUD throughout pregnancy, delivery, and postpartum care when they return to their communities.
O-58. Naloxone should be administered to pregnant patients in cases of opioid overdose.

Reentry
Most patients who require opioid withdrawal management will have OUD. Numerous studies have demonstrated that
treatment with medications for OUD during incarceration and reentry significantly reduces the risk for overdose and
overdose death.49 These studies also found that treatment for OUD with medication reduces illicit opioid use, increases
engagement in OUD treatment in the community, and reduces risks of reincarceration.
If methadone or buprenorphine are abruptly reduced or discontinued upon reentry, patients will be at risk of withdrawal,
as well as at risk for overdose and death.
Recommendations
O-59. Individuals who are being treated with buprenorphine or methadone should continue the medication while in jail,
and the jail should assist with transfer to community-based treatment upon release.
O-60. Qualified health care professionals should ensure the patient has access to an adequate supply of buprenorphine
or methadone to prevent interruption of dosing when the patient transitions to the community.
A. Backup plans are vital in the event the community appointment cannot be completed. Bridging clinics and
telehealth can be very helpful.
O-61. Naloxone or a prescription for naloxone should be made available to all patients with OUD upon release.
A. Jails should consider providing naloxone or a prescription for naloxone to all patients with SUD.
B. Jails should consider making naloxone or a prescription for naloxone available to friends and family members
of patients with SUD.

Stimulant Withdrawal
Approximately 10 percent of the criminal justice population surveyed used methamphetamine or cocaine or misused
prescription stimulants (e.g., nonmedical use of amphetamine products for treating attention-deficit/hyperactivity
disorder) at the time of the offense for which they were incarcerated.50
Stimulant intoxication is marked by multiple indicators (see table S-1), which often present during withdrawal, as well.
In addition, the behavioral signs of intoxication, such as psychosis, hallucinations, and delusions, can be difficult to
distinguish from mental illness.51 Diagnosing stimulant intoxication or withdrawal, or stimulant-induced psychosis, requires
qualified health care professionals.
The Substance Abuse and Mental Health Services Administration (SAMHSA) singles out self-harm as the greatest risk
among patients who are withdrawing from stimulants because of the intensity of depression during withdrawal. The
duration of this depression is longer for individuals who stopped using high doses of methamphetamine than those who
stopped using cocaine.52
Table S-1: Possible Indicators of Acute Stimulant Intoxication53

• Euphoria, heightened sense of self.
• Increased vigor, giddiness, and sense of enhanced mental acuity and performance.
• Agitation, restlessness, irritability.
• Increased alertness.
• Increased sexual libido.
• Poor concentration, although some individuals may report improved concentration.
• Grandiosity, exaggerated self-esteem, egocentricity.
• Hypervigilance.
• Fearlessness.
• Suspiciousness, psychotic symptoms (e.g., paranoia, hallucinations).
• Clarity (not usually disoriented).
• Emotional instability, perceptions of persecution.
• Nausea and vomiting.
• Abnormal body movements.
• Teeth grinding.
• Insomnia.
• Tremors.
• Headache (occasionally).
• Dilated pupils.
• Profuse sweating, often with chills.
• High blood pressure.
• Increased heart rate, with or without an irregular heartbeat and chest pain.
• Elevated temperature.
• Suppressed appetite, weight loss.
Source: Adapted from SAMHSA, 2021, Treatment for Stimulant Use Disorders, Treatment Improvement Protocol (TIP) Series 33.

Screening
Recommendation
S-1. Anyone who reports regular stimulant use (including prescription stimulant misuse), stimulant use disorder, or
stimulant withdrawal risk should be considered at risk for stimulant withdrawal.

As discussed in The Withdrawal Management Process, signs and symptoms of stimulant withdrawal (see table S-2)
typically emerge within 72 hours of incarceration.
Table S-2: Possible Indicators of Stimulant Withdrawal*54

• Agitation
• Anxiety
• Dysphoria/depression
• Intense desire for sleep, often accompanied by insomnia
• Psychotic symptoms
• Strong cravings
• Suicidality/impulsive self-harm
* Staff should be alert to any indicators that the individual is unwell, not only those listed here.
Recommendation
S-2. Custody staff should monitor individuals at risk for stimulant withdrawal at least twice per day for the first 72 hours
from intake.
A. If an individual appears unwell to a layperson, they should be referred for immediate clinical assessment.

Currently, there are no validated clinical assessment tools for stimulant withdrawal. Individuals who appear unwell to a
layperson should be evaluated by a qualified health care professional to determine the types and intensities of treatment
that may be needed.
Health care staff should also be aware of the potential risk for opioid withdrawal. Stimulant drugs may be contaminated
with opioids, including powerful synthetic opioids such as fentanyl. Individuals may not be aware of everything they have
taken and, thus, may not report opioid use or opioid withdrawal risk. If opioid use is suspected, the individual should
be monitored for signs and symptoms of opioid withdrawal and, when necessary, referred for an immediate clinical
assessment.
Recommendations
S-3. The clinical assessment of withdrawal risk should evaluate:
A. Stimulant use in the past 48 hours:
i) Amount used.

ii) Type used (e.g., methamphetamine, amphetamine, cocaine).
iii) Route of administration (intranasal, intravenous, oral, inhalation).
B. Frequency of use (regular daily or binge pattern).
C. Duration of the current period of regular use.
D. Concurrent use of other substances.
E. Psychiatric signs and symptoms.
F. Comorbid psychiatric illness.
S-4. Stimulant withdrawal is not usually associated with medical complications. However, long-term use of stimulants
and stimulant intoxication are risk factors for cardiac complications. Health care and custody staff should be alert
to chest pain and other cardiac symptoms in patients with suspected stimulant withdrawal.
S-5. Health care staff should also monitor for signs and symptoms of opioid withdrawal because the supply of
stimulant drugs is increasingly contaminated or mixed with opioids, and some individuals may not be aware that
they have been using opioids.

Recommendation
S-6. Substance withdrawal is a risk factor for severe depression and suicidality. This risk is particularly high in patients
undergoing stimulant withdrawal. Custody staff should be alert to signs and symptoms of depression in these patients.
Table S-3: Possible Indicators of Depression55

• Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment.
• Appetite and/or weight changes.
• Decreased energy or fatigue.
• Difficulty concentrating, remembering, or making decisions.
• Difficulty sleeping, early-morning awakening, or oversleeping.
• Feelings of guilt, worthlessness, or helplessness.
• Feeling restless or having trouble sitting still.
• Feelings of hopelessness or pessimism.
• Irritability.
• Loss of interest or pleasure in activities.
• Moving or talking more slowly.
• Persistent sad, anxious, or “empty” mood.
• Thoughts of death or suicide, or suicide attempts.
Medications
Treatment for stimulant withdrawal typically consists of behavioral management strategies and, when necessary,
medications for symptom relief. Patients may present with mental health symptoms such as depression, agitation,
suicidality, or stimulant-induced psychosis requiring medical management. For more information on suicide and SUD
withdrawal, see Suicide in General Guidance.

Behavioral strategies, including providing an environment with reduced stimulation with dimmed lights, less noise, and
minimal exposure to other people, can often reduce or prevent agitation. Care should be taken to encourage calm
interactions and avoid situations that may become confrontational during the acute withdrawal phase. This may be
challenging in a jail environment but can provide significant benefits, including reduced violence. Of note, the use of
physical restraints can pose specific health risks in patients experiencing stimulant withdrawal.
Recommendations
S-7. No medications have been proven effective for the treatment of withdrawal from stimulants. However, it may be
appropriate to use medications to relieve symptoms (e.g., agitation, sleep disturbances) during the period of the
withdrawal syndrome.
S-8. The use of medications should be limited to short-term treatment of withdrawal symptoms and to treat accurately
and appropriately diagnosed comorbid conditions.
S-9. If psychosis (beyond mild paranoia) manifests during stimulant withdrawal, it should be treated.
A. Care should be managed in consultation with a qualified mental health care professional.
B. Antipsychotic medication may be required.
C. If psychosis persists or is severe, an immediate assessment by a physician experienced in differential diagnosis

and management of acute changes in mental status is indicated, and general psychosis management and
treatment principles should be applied.
S-10. Patients experiencing agitation that does not immediately respond to behavioral management strategies (e.g.,
minimizing environmental stimulation [e.g., noise, bright lights, crowding]; speaking calmly to the patient; taking
time to listen to and address concerns where appropriate and feasible) should receive an immediate medical
evaluation.
A. Medications for sedation (typically benzodiazepines) may be necessary.
B. Patients whose agitation is not adequately treated with oral medication should be transferred to a hospital
setting.
C. If medications are not available onsite to manage significant agitation, custody staff should transfer the patient
to a medical setting where medications can be provided.
S-11. Benzodiazepines should be avoided unless required for concomitant alcohol or sedative detoxification, or severe
agitation as discussed in the preceding recommendation.
S-12. While depression is common during stimulant withdrawal, it is often secondary to withdrawal and may not
constitute a primary diagnosis. The patient should be monitored to determine if the depression symptoms
improve as the withdrawal syndrome improves.
A. If depression symptoms do not improve, it is appropriate to initiate evidence-based depression treatment.
B. If the patient has a history of depressive disorder, it may be appropriate to initiate antidepressant
medication sooner.

Level of Care
Withdrawal from stimulants that is not complicated by other conditions can typically be safely managed in jails. However,
ongoing or worsening severe depression and other psychiatric complications, as well as acute medical conditions (e.g.,
cardiac issues), may require transfer to a higher level of care.
Recommendations
S-13. As discussed in General Guidance, patients who present with severe psychiatric symptoms including
hallucinations, delusions, paranoia, and delirium, should be immediately transferred to a higher level of care
unless a physician experienced in differential diagnosis of acute changes in mental status is immediately available
for clinical assessment and stabilization.
A. If feasible, medications may be appropriate to stabilize the patient concurrent with the call for transport.
S-14. Transfer to a higher level of care should occur when:
A. The patient displays significant psychiatric complications, and a mental health assessment cannot be provided
immediately.
B. The patient displays significant psychiatric complications (e.g., psychosis, severe depression, suicidal ideation),
and the treatment plan as recommended by a qualified mental health care professional cannot be adequately
or safely managed in the jail setting.
C. The patient presents with acute medical signs or symptoms that cannot safely be managed in the jail (e.g.,
chest pain, markedly elevated or rapidly increasing body temperature, uncontrolled hypertension, seizures).
S-15. Stimulant withdrawal can be managed in a jail setting when the following criteria are met:
A. There are no medical, psychiatric, or behavioral complications requiring a level of medical monitoring or
management that is not available in the facility.
B. The jail has the capacity to safely manage the treatment plan for the patient’s psychiatric complications, as
recommended by a qualified mental health care professional.
Supportive Care
Supportive care may include nutritional supplementation, such as extra food or nutritional shakes, for patients
experiencing stimulant withdrawal (see G-55).
Recommendations
S-16. Withdrawal from stimulants is best undertaken in a calm environment where the patient can rest. Jails should
provide a quiet, non-stimulating environment for patients undergoing stimulant withdrawal, if feasible.
S-17. Often patients undergoing stimulant withdrawal report insomnia and sleep disturbances. Patients should
generally be allowed to sleep for as long they can, unless otherwise ordered by a provider.
A. If the patient has ongoing difficulty sleeping, medications may be necessary.

S-18. Due to the high rates of returning to use following treatment of stimulant withdrawal, psychosocial interventions
should be offered as stimulant withdrawal symptoms wane.
A. An approach focused on improving patient functioning that combines entry into SUD treatment with support,
education, and changes in lifestyle is recommended.
S-19. Any psychological and other supportive therapies initiated during withdrawal should aim to assist the patient to
safely complete withdrawal and to engage in stimulant use disorder treatment following withdrawal.
S-20. As stimulants suppress appetite, patients may have nutritional deficits. A qualified health care professional should
assess patients for nutritional deficits and order nutritional supplementation as needed.

As discussed in General Guidance, pregnant patients should be counseled on substance use in pregnancy and offered
appropriate treatment.
Recommendation
S-21. Stimulant use is associated with a variety of adverse pregnancy outcomes and neonatal complications. Care for
pregnant patients should be managed in consultation with providers experienced with obstetrical care in high-risk
patients and SUD treatment.

Appendixes
Appendix A: Development Team
Appendix B: Full Methodology
Appendix C: Preferred Terminology
Appendix D: ASAM’s Principles of Drug Testing During Withdrawal Management
Appendix E: Monitoring Patients During Withdrawal Management
Appendix F: Withdrawal Pharmacotherapy
Appendix G: Indicators of Dehydration
Appendix H: Expert Committee Members’ Current Industry Relationships
Appendix I: Field Reviewers
Appendix J: Field Reviewers’ Current Industry Relationships
Appendix K: Glossary
Appendix L: Acronym Glossary
Appendix M: Resources

Appendix A: Development Team
Expert Committee
Clinical Experts
Jeffrey Alvarez, M.D., CCHP
Chief Medical Officer, NaphCare
Andrew F. Angelino, M.D.

Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University of Medicine
Kevin A. Fiscella, M.D., M.P.H.

Addiction Medicine Physician, Jordan Health
Miriam S. Komaromy, M.D.

Medical Director, Grayken Center for Addiction at Boston Medical Center
Shannon Robinson, M.D.

Principal, Health Management Associates (HMA)
Sandra Springer, M.D.

Associate Professor of Medicine in the Department of Internal Medicine,
Section of Infectious Diseases Yale School of Medicine
Marc F. Stern, M.D., M.P.H.

Affiliate Assistant Professor, School of Public Health, University of Washington
Faculty, School of Public Health University at Albany
Chief Medical Advisor for the National Sheriffs’ Association (NSA), American Jail Association (AJA),
and Washington Association of Sheriffs and Police Chiefs
Donna Strugar-Fritsch, B.S.N., M.P.A., CCHP

Correctional Health Care Consultant
Experts in Jail Administration

Oscar Aviles, CPM, CJM, CCE, CCHP
Assistant County Administrator, Hudson County (New Jersey)
Jeff Clark, M.J.A.

Undersheriff, Washoe County Sheriff’s Office

Carrie Hill, Esq.
Executive Director, Massachusetts Sheriffs’ Association
Chief Jail Advisor, NSA
Geoff Stobart
Chief Deputy of Research, Development, and Major Projects for the Franklin County Sheriff’s Office (Columbus, Ohio)
Federal Project Champions

Stephen Amos, M.S.
National Institute of Corrections (NIC) Technical Lead
Chief, Jails Division
NIC, U.S. Department of Justice (DOJ)
Margaret Chapman, M.A.

Bureau of Justice Assistance Project Manager
Policy Advisor
BJA, DOJ
Ruby Qazilbash, M.P.A.

BJA Assistance Technical Lead
Deputy Director
BJA, DOJ
Technical Support Team

Maureen Boyle, B.A., Ph.D.
Executive Scientific Lead
Chief Quality and Science Officer, ASAM
Linda Frazier, B.S., M.A., RN, MCHES

Clinical Liaison
Director, Addictions Initiatives, Advocates for Human Potential, Inc. (AHP)
Brent Gibson, M.D., M.P.H., CCHP-P

Former Chief Health Officer
National Commission on Correctional Health Care (NCCHC)
Wendy Habert, M.B.A., PHR, CCHP

Director of Accreditation, NCCHC
Laura Lutgen-Nieves, Ph.D.

Literature Review Author
Assistant Professor, Department of Criminal Justice, University of Southern Indiana

Jim Martin
Team Project Manager
Vice President of Program Development, NCCHC
Kay S. Peavey
Lead Writer
Deputy Director, Technical Writing, AHP
Pam Rainer, M.S.W.

Corporate Lead
Senior Program Director, AHP
Deann Rogers, M.S.

Project Management Lead
Director, Technical Writing, AHP
Deborah Ross
Project Oversight
Chief Executive Officer (CEO), NCCHC
Taleen Safarian
Project Support
Senior Manager, Science & Dissemination, ASAM
Jaime Shimkus
Communications Support
Former Vice President of Communication, NCCHC
Kim Sterling
Marketing/Communications Support
Vice President of Professional Services, NCCHC
Claire Wolfe
Project Management Associate
Research Associate, NCCHC

Appendix B: Full Methodology
Overview of Approach
These guidelines were developed using a modified RAND/UCLA Appropriateness Method (RAM). The RAM process
is a deliberate approach encompassing review of existing clinical guidelines and standards, literature reviews,
appropriateness and feasibility ratings, stakeholder comment and reconciliation, and document development. The
process typically combines scientific evidence and clinical knowledge to determine the appropriateness of a set of
clinical procedures. This process was modified for the development of these guidelines to incorporate the input of
jail administration experts and others with legal expertise regarding implementation of guidelines and procedures in
jail settings.
RAM is particularly appropriate for the matter at hand for two reasons. First, there are few randomized clinical trials
(RCTs) directly addressing the implementation of withdrawal management in criminal justice settings. Second, evidence
supporting the efficacy of treatments for different withdrawal syndromes reflects varying years of research and varying
levels of evidence (e.g., nonrandomized studies, retrospective studies). The RCT is the gold standard for evidence-based
medicine. When data are lacking from RCTs, other methods (i.e., reviewing second-tier research and using a delphi
process for consensus development) are used to help health care professionals make the best choices. In addition,
individuals in the criminal justice system are often excluded from RCTs, requiring clinical expertise to interpret available
studies in the context of a jail setting and population. The modified RAM process used for the development of these
guidelines combined the best available scientific evidence with the collective judgment of clinical and jail administration
experts to yield statements about the appropriateness and feasibility of specific procedures that can be applied to
implementation of withdrawal management in jail settings.

The Bureau of Justice Assistance (BJA), National Institute of Corrections (NIC), Advocates for Human Potential, Inc.
(AHP), National Commission on Correctional Health Care (NCCHC), and American Society of Addiction Medicine
(ASAM) provided oversight for guideline development, including the selection of expert committee (EC) members. To
avoid actual, potential, or perceived conflicts of interest that may arise because of relationships with industry and other
entities, EC members were required to disclose all current related relationships (see appendix H). All field reviewers (see
appendix I) of these guidelines were also asked to disclose all current related relationships (see appendix J).
Briefly, a structured literature review (see Task 1) was conducted to identify the most up-to-date evidence on the clinical
management of substance withdrawal and implementation of withdrawal management in criminal justice settings,
including published and unpublished clinical guidelines. This evidence was used by the EC to inform the development of
draft recommendation statements.
The clinical experts on the EC then rated the appropriateness of the draft recommendation statements on a 9-point
scale, while the jail administration experts rated the feasibility of the draft recommendation statements on a 9-point
scale. The ratings were analyzed for consensus or discordance. Statements for which there was a divergence of
appropriateness ratings were discussed by the EC. In addition, items flagged for feasibility challenges were discussed
by the EC to determine if there were ways to amend the statements to provide additional flexibility to support
implementation without undermining patient safety. After each meeting, the information gathered was used to revise
several of the statements, and the EC was asked to re-rate these.
All the identified draft statements and supporting research were incorporated into an outline defining each specific
section to be included in the document, as well as narrative setting the stage for the statements. A draft document
included three rounds of review and comment: the first round to internal reviewers, a revised version sent to EC
members, and the third round involving solicitation of field reviewer feedback. All external feedback collected was
catalogued, reviewed, tracked, and addressed, discussing any issues raised during this feedback reconciliation process
with the EC through several meetings. Recommendation statements and narrative content were then revised based on
the committee’s feedback, securing EC approval on all revised and new recommendation statements through rounds
of appropriateness and feasibility ratings and discussion, as well as internal reviewer feedback (BJA/NIC/AHP/ASAM/
NCCHC/EC), to produce the final draft.
Task 1: Literature Review

Scientific Literature Review
To review the most up-to-date evidence on the clinical management of substance withdrawal, a structured literature
review was conducted. The literature review included clinical studies with randomized and nonrandom assignment and
excluded case studies. Articles were identified through searches conducted in PubMed using predefined search terms
and selection criteria. Additional articles were identified through forward and reverse citation search of key articles.
To develop recommendations for management of opioid and alcohol withdrawal in jails, The ASAM National Practice
Guideline for the Treatment of Opioid Use Disorder and The ASAM Clinical Practice Guideline on Alcohol Withdrawal
Management, both released in 2020 with literature reviews completed in late 2018, were used as foundational clinical
standards. The literature review for opioid and alcohol withdrawal, therefore, focused on studies addressing criminal
justice-specific implementations published in the 10-year period from 2011 to 2021.
To develop recommendations for the management of sedative and stimulant withdrawal, SAMHSA’s Detoxification and
Substance Abuse Treatment, Treatment Improvement Protocol (TIP) 45 was used as the foundational clinical standard.
A search for literature on management of withdrawal from these substances was conducted for the past 10 years (from

2011 to January 2021), to account for research published during development of this guidance, last published in 2015.
Targeted searches were also conducted for studies examining the implementation of withdrawal management in criminal
justice settings.
Searches included all fields (e.g., titles, abstracts, keywords). Titles and abstracts were reviewed for inclusion by a senior
member of the research team. Articles were restricted to English language and human participants. If an article reflected
a secondary analysis of data from a relevant study, the original report was included in the literature review.
The literature search yielded 2,833 articles. The titles and abstracts were reviewed to determine if the study met the
inclusion/exclusion criteria, and those that did not, or could not be obtained, were removed (n = 2,403). The remaining
430 articles were then reviewed for inclusion, and 172 articles were ultimately retained for use in the literature review, as
the others did not meet the predetermined inclusion/exclusion criteria. Key data were extracted from these articles and
presented to the EC.
Gray Literature Review

A targeted internet search of gray literature (literature not available through traditional commercial or academic
publications) was also conducted, including published and unpublished clinical guidelines and prominent systematic
reviews related to withdrawal management or suicide prevention. The following websites were searched using the onsite
search engines:
• Substance Abuse and Mental Health Services Administration
• U.S. Department of Veterans Affairs
• The Indian Health Service
• The World Health Organization
• The Agency for Healthcare Research and Quality
• The National Academies of Sciences, Engineering, and Medicine
• Guideline Central
• Cochrane Reviews
A general internet search was also conducted to identify international clinical guidelines related to withdrawal
management or suicide prevention. The gray literature search was not time limited, but where recommending bodies
had published updates of guidelines, only the most recent was included. Search terms for the gray literature search
were withdrawal-related terms including, but not limited to, “detoxification” and “withdrawal.” In total, 83 guidelines
were identified.
The aim of this exercise was not to re-review all the research literature, but to identify within the existing clinical
guidelines common questions or considerations health care professionals are likely to have with regard to the
management of withdrawal and prevention of suicide, with a specific focus on practical management within jail settings.

The six guidelines listed below represented high quality clinical guidance addressing the broad clinical issues related to
management of withdrawal from alcohol, opioids, sedative/hypnotics, and stimulants, and addressing management of
withdrawal in closed settings flagged for EC members.
• The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder, 2020 Focused Update (2020)
• Detoxification and Substance Abuse Treatment: Treatment Improvement Protocol (TIP) 45 (2015), from SAMHSA
• Medically Supervised Withdrawal for Inmates with Substance Use Disorders (2020), from the Federal Bureau
of Prisons
• The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management (2020)
• Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings (2009), from
the World Health Organization
• Models of Intervention and Care for Psychostimulant Users (2004), from the Australian Government Department of
Health and Ageing
These clinical documents were each developed using standard methodologies incorporating structured literature reviews
and formal expert consensus development processes. They were used as the foundation for the development of draft
recommendation statements (discussed below).
The EC was provided with the literature review summary, tables of key abstracted information from the scientific
literature, and the guidelines identified in the gray literature search. This information was used by the EC to inform their
discussion and judgments in Task 2.
Task 2: Identification of Draft Statements and Appropriateness/

Feasibility Rating
The next step in the RAM was to develop a set of draft recommendation statements, which were derived from
the guideline analysis and informed by the literature review and EC’s collective expertise. Each member of the EC
reviewed the guidelines and literature review. The EC worked with the technical support team to draft recommendation
statements. The EC then independently rated the 744 draft recommendation statements on a 9-point scale. The clinical
experts on the committee rated the statements for appropriateness, and the jail administration experts rated the
statements for feasibility within a jail setting.
A statement was considered appropriate if the expected health benefit (e.g., increased life expectancy, relief of pain,
reduction in anxiety, improved functional capacity) exceeded the expected negative consequences (e.g., mortality,
morbidity, anxiety, pain) by such a sufficiently wide margin that the recommendation is worth following, exclusive of cost.
These appropriateness ratings were meant to identify consensus, or a lack thereof, in existing guidance and research
literature. A statement was considered feasible if there was reasonable likelihood that it could be implemented in the
context of an average patient presenting to an average jail. Administrators were instructed to consider the literature
review as well as their own best judgment, considering relevant factors (e.g., economic, technical, legal, workforce).

Guideline Committee Meetings
Upon completion of the individual committee member ratings, the rating results were analyzed for consensus or
discordance. Statements for which there was a divergence of rating scores were discussed by the EC. Items flagged
for feasibility challenges were also discussed by the entire committee to determine if there were ways to amend the
statements to provide additional flexibility supporting implementation without undermining patient safety. After each
meeting, the information and decisions gathered were used to revise many of the statements, and the committee was
asked to re-rate the revised statements.
Creation and Revision of Outline

All identified appropriate hypothetical statements and supporting research were incorporated into an outline defining
each specific section to be included in these guidelines. The draft outline was sent to all committee members for review
and comment prior to finalization.
Creation and Revision of Draft

The outline served as a framework for the narrative that supports the statements to create the first draft. As described
above, through many discussions with the EC, rounds of ratings, multiple internal reviews, a field review, and draft
revisions, a final version of these guidelines was created.

Appendix C: Preferred Terminology
Use of person-first language and preferred terminology, which is reflected throughout these guidelines, reduces stigma,
negative bias, and the perpetuation of stereotypes when speaking about or to individuals experiencing withdrawal or
with substance use disorder (SUD).
Use … Instead of … Because …

• Individuals who are detained in jail • Inmate • Recognizes that people are not their crimes
• Individuals who enter jail • Criminal or criminal history.
• Person who has criminal justice system • Offender • Advances language that is accurate and not
involvement prejudicial.
• Justice-involved person
• Person who was formerly incarcerated • Felon
• Substance use disorder • Substance abuse • Avoids negative connotations and the
• Substance use • Drug habit undermining of SUD as a serious health
condition.
• Person with a substance (opioid, alcohol, • Addict • Reflects an accurate, science-based
stimulant) use disorder • Drug or substance user understanding that the person has a
• Individuals who exhibit signs of withdrawal medical condition.
• User
or withdrawal symptoms • Recognizes that the person has a disorder,
• Dope addict rather than “is the disorder.”
• Individuals who report using substances
(alcohol, opioids, stimulants) • Alcoholic • Avoids negative associations, punitive
• Pregnant person with an opioid use • Drug addict attitudes, individual blame, judgment, and
disorder • Pregnant opiate addict misinformation about SUD.
• Reinforces use of the same terminology as
• Individuals who screen negative/positive • Dirty/clean screen
with other medical conditions.
(e.g., withdrawal, suicide risk) • Dirty results
• Encompasses the recovery process of
• Positive/negative screen result • Failing drug screen/test improved health versus the implication that
• Person in recovery • Former addict the person was “dirty” before recovery.
• Person in long-term recovery • Former drug user
• Person who has maintained recovery • Former alcoholic
• Person who “stayed clean”
• Return to use • Relapsed • Advances language that is medically
• Experienced a recurrence • Slipped accurate and non- stigmatizing.
• Resumed drinking or using drugs • Chronic relapser
Compiled from the Bureau of Justice Assistance, the National Institute on Drug Abuse, the Justice Community Opioid
Innovation Network, and the National Council for Mental Wellbeing.56

Appendix D: ASAM’s Principles
of Drug Testing During
Withdrawal Management
1. Drug tests can be used to help inform clinical decisionmaking for patients with substance use disorder (SUD) or at
risk for substance withdrawal.
2. Drug tests can neither diagnose SUD nor rule out SUD.
3. Drug test results should be used in combination with the patient history, physical exam, and psychosocial
assessment to determine care plan.
4. Drug testing can be an important supplement to patient self-report because patients may not be aware of the
composition of the substances they have used.
5. Test selection should be individualized based on specific patients and clinical scenarios. Before choosing the type of
test and matrix, the provider should determine the questions they are seeking to answer and consider the benefits
and limitations of each test and matrix (e.g., urine, blood, saliva, hair, etc.). The methods used will impact the
interpretation of the results:
a. Each matrix has advantages and disadvantages (e.g., ease of collection, window of detection, susceptibility to
tampering, etc.).
b. Tests are designed to measure whether specific substances have been used within particular windows of time.
c. Drug testing panel selection should be based on the patient’s self-reported use, prescribed medications, and
drugs commonly used in the geographic area and in the patient’s peer group.
i. Note that many drug test panels do not detect fentanyl, fentanyl analogs, methadone, buprenorphine,
norbuprenorphine, and many other commonly used and/or misused substances.
d. It is important to understand the difference between presumptive drug tests (routinely used for point-of-care
testing) and definitive tests (used to confirm results of presumptive tests and rule out false positives).
i. Definitive tests are laboratory tests that are conducted in Clinical Laboratory Improvement Amendments-
certified laboratories.

6. Definitive testing should be used when the results inform clinical decisions with major clinical or non-clinical
implications for the patient (e.g., changes in medications, changes in legal status).
7. Drug test results should be interpreted by a provider whose scope of practice includes ordering and interpreting
drug test results, who will consider the limitations of the specific test used.
8. Discrepancies between the patient self-report and the drug tests should be discussed with the patient.
9. Providers should keep test results ordered by health care staff confidential to the extent permitted by law.
10. Providers should be aware of the adverse legal and social consequences of detecting substance use in pregnant
patients. The patient should be made aware of local/state reporting requirements and provide consent before tests
are conducted.
For more information, go to ASAM’s Appropriate Use of Drug Testing in Clinical Addiction Medicine.

Appendix E: Monitoring Patients
During Withdrawal Management
WARNING: Supply patterns across the country show that drugs used in the community are often mixed with illicitly
manufactured fentanyl and other drugs, such as xylazine. The most frequent monitoring noted is the minimum
expectation, but providers may need to increase monitoring, based on their best clinical judgment and knowledge
of local drug-use trends.
Substance Minimum Frequency and Use of Withdrawal Symptom Assessment Scale*
Alcohol Re-assessment using the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) at least
every 8 hours during alcohol withdrawal management until the CIWA-Ar score remains below 10 for 24 hours.
• If the CIWA-Ar is ≥ 19, repeat the CIWA-Ar at least every 6 hours during alcohol withdrawal management
until the score falls below 19, and then continue monitoring with the CIWA-Ar at least every 8 hours until the
score remains below 10 for 24 hours.
Sedatives • Daily clinical assessment by a qualified health care professional for at least the first week or as condition
indicates.
• After the first week, re-assessment by a qualified health care professional at least two times per week until
withdrawal management is complete.
Opioids • Monitoring using the Clinical Opiate Withdrawal Score (COWS) at least every 4 hours for patients who report
use of a short-acting opioid (e.g., heroin, oxycodone, fentanyl).
• Monitoring using the COWS at least every 8 hours for patients who report using long-acting opioids (e.g.,
extended-release formulations, methadone).
Stimulants • Monitoring, at an interval determined by the treating clinician, for suicide risk, cardiac complications, severe
or persistent psychosis, significant agitation, and possible opioid withdrawal (due to potential contamination
of stimulant drugs).
*As noted in G-25, clinical assessments should be conducted by qualified health care professionals not less than twice per day, not more than 16 hours
apart (unless otherwise stated in the substance-specific guidance in this document and summarized in table 1 above).

Appendix F: Withdrawal
Pharmacotherapy
No medications have been approved by the FDA to treat stimulant withdrawal; therefore, that section describes
behavioral management strategies as first-line treatment. Stocking medications for symptom relief is also recommended.
Table 2: Withdrawal Pharmacotherapy

Substance Recommended Pharmacotherapy For More Information
Alcohol Benzodiazepines, long-acting preferred (i.e., diazepam The ASAM Clinical Practice Guideline on Alcohol
or chlordiazepoxide), except for older adults or Withdrawal Management
individuals with impaired liver function
Opioid Methadone or buprenorphine The ASAM National Practice Guideline for the
Treatment of Opioid Use Disorder: 2020
Focused Update
Sedatives Long-acting benzodiazepine (e.g., clonazepam) Detoxification and Substance Abuse Treatment,
Treatment Improvement Protocol (TIP) Series, No. 45

Appendix G: Indicators
of Dehydration
Table 3: Indicators of Dehydration57

Mild Dehydration Life-threatening Dehydration
• Feeling very thirsty • Confusion
• Dry mouth • Fainting
• Urinating and sweating less than usual • Lack of urination
• Dark-colored urine • Rapid heartbeat
• Dry skin • Rapid breathing
• Feeling tired • Shock
• Dizziness

Appendix H: Expert Committee
Members’ Current Industry
Relationships
Expert Salary Consultant Expert Witness Ownership, Institution,

Committee Partnership, Organization, or
Member or Principal Other Financial
Benefit
Jeffrey Alvarez, M.D., NaphCare, Inc. None None None None
CCHP-P, CCHP-A
Andrew F. Angelino, Johns Hopkins School None Administrative Law None None
M.D. of Medicine Hearings - Involuntary
Commitment
Oscar Aviles, CPM, Hudson County None Correctional None None
CJM, CCE, CCHP Administrator’s Office Employment Litigation
Jeff Clark Washoe County None None None None
Sheriff’s Office
Kevin Fiscella, M.D., University of None None None NCCHC Board
M.P.H., CCHP Rochester Member
Carrie Hill, Esq. Massachusetts Sheriff’s National Correctional Deliberate None Justice Community
Association Law, Training, Policy indifference regarding Opioid Innovation
Consulting medical care Network Practitioner’s
Board Member
NSI II training for NIC/ Use of force
JJSC NSA, Chief Jail
Advisor
Miriam Komaromy, Boston Medical None None None ASAM Board of
M.D. Center, Boston Directors Member
University
Shannon Robinson, HMA None None None Harm Reduction
M.D., CAP Solutions
(domestic partner)
Sandra Springer, M.D. Yale School of Alkermes, Inc. None None NIH-funded research
Medicine and U.S. Department
of Veterans Affairs
(VA)-sponsored
research; Indivior
(in-kind donation)
Marc Stern, M.D., Consultant Consultant Correctional Health None None
M.P.H. Care
Donna Strugar-Fritsch, Consultant Consultant None None Former employee of
B.S.N., M.P.A., CCHP HMA
Geoff Stobart Franklin County None None None None
Sheriff’s Office

Appendix I: Field Reviewers
American Academy of Addiction Psychiatry (AAAP)

Elie G. Aoun, M.D., MRO, FAPA
General, Addictions and Forensic Psychiatrist
Assistant Professor of Clinical Psychiatry, Columbia University, Division of Law, Ethics, and Psychiatry
Co-chair, AAAP Committee on Law and Addiction
Laurence M. Westreich, M.D.

Addiction and Forensic Psychiatry
Co-chair, AAAP Committee on Law and Addiction
Associate Professor of Clinical Psychiatry
Department of Psychiatry, New York University School of Medicine
American College of Academic Addiction Medicine (ACAAM)

Marsha J. Wunsch, M.D., FAAP DFASAM
Past President, ACAAM, Addiction Medicine Consultant
Alameda County Santa Rita Jail
American College of Medical Toxicology (ACMT)

Joseph Carpenter, M.D.
ACMT Addiction Medicine Committee, Communication Subcommittee Chair
Assistant Professor of Emergency Medicine, Emory University School of Medicine
Leslie R. Dye, M.D., FACMT, FASAM, FACCT

ACMT Addiction Toxicology Committee Chair and Past-President
Addiction Medicine Section Editor and former Editor-in-Chief, Journal of Medical Toxicology
Ashley Haynes, M.D.

ACMT Addiction Medicine Committee, Practice Subcommittee Chair
Program Physician, Wichita Comprehensive Treatment Center
American College of Obstetricians and Gynecologists (ACOG)

Carolyn Sufrin, M.D., Ph.D.
Associate Professor of Gynecology and Obstetrics, Johns Hopkins School of Medicine
Tricia Wright, M.D., M.S., FACOG DFASAM

Professor of Clinical Medicine, University of California San Francisco
Christopher M. Zahn, M.D.

Chief, Clinical Practice and Health Equity and Quality, ACOG

American Correctional Association (ACA)
Jeffrey Washington
Deputy Executive Director, ACA
American Jail Association (AJA)

Diana L. Knapp
Director, Jackson County Sheriff’s Office
Henry Reyes, M.A.M., M.P.A., CJM, CCE, NCCE

Chief Deputy, Detention Bureau/Housing, Tarrant County Sheriff’s Office
Darren Sieger, M.S., CJM

Director—Administration, Broward Sheriff’s Office, Department of Detention
Marsha Travis, CJM, CCM, CBHC

Director of Standards and Accountability, Nashville-Davidson County Sheriff’s Office
American Osteopathic Academy of Addiction Medicine (AOAAM)

Jon Lepley, D.O., FASAM, FAOAAM, CCHP
Medical Director, Addiction Medicine, Penn Medicine Lancaster General Health
American Psychiatric Association (APA)

Smita Das, M.D., Ph.D., M.P.H.
Clinical Associate Professor, Stanford University School of Medicine
Dionne Hart, M.D., DFAPA, FASAM

Medical Director, Care From The Hart
AMA Representative to NCCHC
American Society of Addiction Medicine (ASAM)

Margaret A. E. Jarvis, M.D., DFASAM
Chief, Addiction Services, Geisinger Health System
Hendree Jones, Ph.D.

Executive Director, University of North Carolina at Chapel Hill Horizons
Kelly S. Ramsey, M.D., M.P.H., M.A., FACP, DFASAM

Associate Chief of Addiction Medicine, New York State Office of Addiction Services and Supports
Mishka Terplan, M.D., M.P.H., FACOG, DFASAM

Medical Director/Senior Research Scientist, Friends Research Institute
R. Corey Waller, M.D., M.S., FACEP, DFASAM

Chief Medical Officer, Brightview Health

Aleksandra Zgierska, M.D., Ph.D., DFASAM
Professor and Vice-chair of Research, Penn State College of Medicine
Community Oriented Correctional Health Services (COCHS)

Michael DuBose
Chief Operating Officer
Daniel Mistak
Director of Health Care Initiatives for Justice-involved Populations
Major County Sheriffs of America (MCSA)

Laura Bedard, Ph.D.
Chief of Corrections, Seminole County Sheriff’s Office
Kyle Prichard
Mental Health Specialist, Seminole County Sheriff’s Office
Vincent Wasilewski
Chief Custody Deputy, Santa Barbara Sheriff’s Office
National Association of Addiction Treatment Providers (NAATP)

Mark Dunn
Director of Public Policy
National Association of Counties (NACo)

Brett Mattson
Legislative Director, Justice & Public Safety, Gulf States Counties & Parishes Caucus
Nastassia Walsch
Director of Programs and Operations
National Council for Mental Wellbeing (National Council)

Aaron Williams, M.A.
Senior Advisor, Practice Improvement & Consulting
National Sheriffs’ Association (NSA)

Christopher L. Barnes, J.D.
Legal Advisor, Collin County Sheriff’s Office
Small & Rural Law Enforcement Executives Association (SRLEEA)

Chief John W. Thompson, Ret.
Executive Vice President


Appendix J: Field Reviewers’
Current Industry Relationships
External Representing Salary Consultant Expert Witness Ownership, Institution,

Reviewer Partnership, Organization,
or Principal or Other
Financial
Benefit
Elie G. Aoun, AAAP Columbia University None opioids, correctional None None
M.D., MRO, FAPA mental health
treatment, divorce,
custody, criminal
matters
Laura Bedard, MCSA Seminole County Consulted on Spouse None None
Ph.D. Sheriff’s Office Tennessee case
Joseph Carpenter, ACMT Emory University School None None None None
M.D of Medicine
Smita Das, M.D., APA* Lyra Health None None None None
Ph.D., M.P.H.
Michael DuBose COCHS COCHS None None None None
Dionne Hart, M.D., APA DOJ, Bureau of Prisons None Civil commitment None AMA rep. to
DFAPA, FASAM hearing, testimony NCCHC
regarding patient’s
current mental health
status
Ashley Haynes, ACMT Wichita Comprehensive None None None None
M.D. Treatment Center
Margaret A. E. ASAM Geisinger Health System None Legal cases & None ABPM
Jarvis, M.D., American Board for
DFASAM Preventive Medicine
Hendree Jones ASAM UNC Horizons None None None None
Ph.D.
Diana L. Knapp AJA Jackson County Sheriff’s None None None None
Office
Jon Lepley, D.O., AOAAM Penn Medicine Lancaster None None None None
FASAM, FAOAAM, General Health
CCHP
Daniel Mistak COCHS COCHS None None None None
Kelly S. Ramsey, ASAM NYS OASAS None None None None

M.D., M.P.H., M.A.,
FACP, DFASAM
Henry Reyes, AJA Detention Bureau None None None None
M.A.M., M.P.A., Tarrant County Sheriff’s
CJM, CCE, NCCE Office

External Representing Salary Consultant Expert Witness Ownership, Institution,
Reviewer Partnership, Organization,
or Principal or Other
Financial
Benefit
Darren Sieger, AJA Broward Sheriff’s None None None None
M.S., CJM Office, Department of
Detention
Carolyn Sufrin, ACOG Johns Hopkins School of None None None NCCHC Board of
M.D., Ph.D. Medicine Directors
Mishka Terplan ASAM Friends Research None None None Foundation for
M.D., M.P.H., Institute Opioid Response
FACOG, DFASAM Efforts Scientific
Advisory
Committee,
AAPM’s SUD
Shared Interest
Group Co-Chair
Marsha Travis, AJA Nashville-Davidson None None None None
CJM, CCM, CBHC County Sheriff’s Office
Chief Custody MCSA Santa Barbara Sheriff’s None None None None
Deputy Vincent Office
Wasilewski
Laurence M. AAAP New York University Baseball None None Major League
Westreich, M.D. School of Medicine Commissioner Baseball
(consultant)
R. Corey Waller, ASAM Brightview Health None None None None
M.D., M.S., FACEP
DFASAM
Aaron Williams National Council National Council for None None None None
Mental Wellbeing
Tricia Wright, ACOG University of California McKesson McKesson Opioid None None
M.D., M.S., San Francisco lawsuit
FACOG DFASAM
Martha J. Wunsch, ACAAM Alameda County Santa None None None None
M.D., FAAP Rita Jail
DFASAM
Christopher M. ACOG ACOG None None None None
Zahn, M.D.
Aleksandra ASAM Penn State College of Federal &
Zgierska, M.D., Medicine local research
Ph.D., DFASAM grants awarded
institution for
the projects led
by me, Member
of the Data and
Safety Monitoring
Board (DSMB)
for three NIDA-
funded studies
Conflicts of interest were not collected from federal field reviewers.

Appendix K: Glossary
Definitions in this glossary were largely derived and adapted from evidence-based guidance documents and other
reputable, field-accepted sources, as well as input from clinical and criminal justice experts.
Alcohol use disorder: A substance use disorder involving alcohol.58
Alcohol withdrawal delirium (formerly known as delirium tremens): A severe manifestation of alcohol withdrawal
involving sudden and severe mental or nervous system changes. Clinical features include hallucinations, acute
disorientation and confusion, autonomic instability, agitation, and paranoia.59, 60
Alpha-2 adrenergic agonists: A class of drugs (FDA-approved lofexidine and off-label clonidine) that activate alpha-2
adrenoceptors. These medications are often used to treat anxiety and hypertension and may also be used to help
manage withdrawal symptoms when clinically appropriate.61, 62
Anxiolytics: A class of medications that help reduce the symptoms of anxiety.63
Appears unwell: Observed signs, symptoms, or indications by a layperson that (1) an individual may be sick (physically
or psychologically); or, (2) in the case of a patient who has already been assessed by a qualified health care professional,
the patient’s condition is worsening, becoming unstable, or becoming a danger to self or others. This term is applied
throughout to encourage a layperson to err on the side of caution when determining whether to refer an individual to a
qualified health care professional.
Asymptomatic: Showing no symptoms.64
Ataxia: Lack of muscle control or coordination.65
Autonomic instability: Fluctuation of heart rate, blood pressure, sweating, and other nonvoluntary body functions.66
Barbiturates: A class of sedative and sleep-inducing drugs derived from barbituric acid,67 primarily used to treat seizure
disorder, anxiety, and insomnia. They are known on the street by various names (e.g., phennies, reds and blues, tooies,
yellow jackets).68
Benzodiazepines: Sedative drugs commonly prescribed for anxiety or to help with insomnia.69 Long-acting
benzodiazepines are the most commonly used and preferred pharmacotherapy agents for treating alcohol and sedative
withdrawal. Commonly prescribed benzodiazepines include alprazolam (Xanax®), lorazepam (Ativan®), clonazepam
(Klonopin®), diazepam (Valium®), and temazepam (Restoril®).70 Benzodiazepines are commonly referred to as Xanbars,
downers, never pills, tranks, and benzos.
Clinical assessment: An evaluation conducted through a clinical encounter by a qualified health care professional who
is either licensed or certified and may include psychological, laboratory, or other testing and compilation of collateral
information from others who are in close proximity to the individual.71
Comorbidity: Concurrent substance use and physical or mental disorders.72

Complicated withdrawal: Severe withdrawal symptoms involving seizures, hallucinations, delirium, or psychosis, which
require more frequent monitoring and may require hospital-level care.
Cravings: Desire to use substances or engage in addictive behaviors, experienced as a physical or emotional need for
reward and/or relief.73
Custodial facility: Refers to confines such as jail, detention, holding, or lockup facilities.
Custody staff: Line security, as well as correctional administration.74
Delirium: A mental state in which a patient is confused, disoriented, and not able to think or remember clearly. It usually
starts suddenly and is often temporary and treatable.75
Differential diagnosis: Consideration of possible disorders that could be causing symptoms. It often involves several
tests to rule out conditions and/or determine if a patient needs more testing. It is used to help differentiate physical or
mental health disorders that cause similar symptoms.76
Emergent: Arising suddenly and unexpectedly, calling for quick judgment and prompt action.77
Fetal alcohol spectrum disorder: An umbrella term referring to a range of effects caused by prenatal exposure
to alcohol.78
Fixed dosing: An approach where a predetermined dose (which can be determined based on withdrawal severity) is
administered at fixed intervals according to a schedule. Doses usually decrease in a gradual taper over several days.
Additional medication may be provided if the fixed-dose does not adequately control symptoms.79
Front loading: An approach where moderate to high doses of a long-acting medication are given frequently at the start
of treatment to achieve rapid control of withdrawal signs and symptoms. Front loading can be followed by a symptom-
triggered or fixed-dose regimen.80
Gamma-hydroxybutyric acid (GHB): Sodium oxybate, which is prescribed for daytime sleepiness and muscle weakness
associated with sleep disorders. Also produced illegally for illicit use, it is commonly known as “liquid ecstasy” and the
“date rape drug,” the latter for its enhanced effect and undetectable presence when mixed with alcohol.81, 82
Injection: Administering a liquid medication or substance within the body through a needle and syringe (intravenous,
subcutaneous, intramuscular).
Intoxication: A clinical state marked by dysfunctional changes in physiological functioning, psychological functioning,
mood state, cognitive process, or all of these, as a consequence of consumption of a psychoactive substance.83
Korsakoff syndrome: Chronic changes in mental status and memory that often follow an episode of Wernicke
encephalopathy; occurs primarily in cases of severe, chronic alcoholism and is caused by thiamine (vitamin B1) deficiency
and damage to the mammillary bodies (small, spherical nuclei at the base of the brain).84, 85
Layperson: A person with no certification, licensure, specific health care training, or professional or specialized
knowledge in health care.
Level of care: Distinct clinical and environmental support services of various intensities available in a variety of settings.86

Licensed prescriber: A nurse practitioner, physician assistant, physician, or other health care provider licensed to
prescribe medications. Note that state laws may vary with regard to prescribing authorities.
Methadone treatment provider: Authorized provider of methadone (e.g., opioid treatment programs are certified by
SAMHSA to treat patients with opioid use disorder using methadone).
Micro-dosing: Administration of buprenorphine–naloxone in a small initial dose with incremental increases to both dose
and frequency over time.87
Misuse: Misuse of prescription drugs means taking a medication in a manner or dose other than prescribed; taking
someone else’s prescription, even if for a legitimate medical complaint such as pain; or taking a medication to feel
euphoria (i.e., to “get high”).88
Monitoring: Regular and active surveillance to detect changes in physical or mental status that may indicate health
problems, which facilitates appropriate interventions and ensures patient safety.89, 90
Narcotic treatment program: The Controlled Substances Act and U.S. Drug Enforcement Administration (DEA)
regulations refer to opioid treatment programs as narcotic treatment programs, which are registered with the DEA.91
Older adult: Individuals who are 55 years and older.92
Opioid: Any psychoactive chemical resembling morphine in pharmacological effects, including opiates and synthetic/
semisynthetic agents.93
Opioid agonist: A medication that occupies and activates opioid receptors in the body.94
Opioid antagonist: A medication that occupies opioid receptors in the body but does not activate the receptors. This
effectively blocks the receptor, preventing the brain from responding to other opioids. The result is that further use of
opioids does not produce analgesia, euphoria, or intoxication.95
Opioid use disorder: A substance use disorder involving opioids.96
Opioid withdrawal syndrome: The wide range of symptoms occurring when individuals who regularly take opioids,
either illicit or prescribed, stop or reduce their use.97
Patient: As used in this document, a person whose substance withdrawal or SUD is being treated.98
Patient navigator: A person whose role is to help individuals who are transitioning to new circumstances understand
system processes and how to effectively navigate systems to obtain services needed and access resources; for purposes
of this document, this transition is from jail to the community. Often, patient navigators have lived experience with a
substance use disorder and/or involvement with the criminal justice system.99
Pharmacokinetics: The study of how pharmacological agents are processed within a biological system, including factors
that influence the absorption, distribution, metabolism, and elimination of a substance or its metabolic products.100
Pharmacotherapy: Therapy (medical treatment) using pharmaceutical drugs.101
Physician: A designated doctor of medicine or osteopathy who has the final authority at a given facility regarding
clinical issues.

Physiological dependence: Adaptation of a body to a substance, requiring more of it to achieve a certain effect
(tolerance) and eliciting substance-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal).102
Precipitated withdrawal: A condition that occurs when an opioid agonist is displaced from the opioid receptors by
an antagonist or partial agonist in an individual who is dependent on opioids. Precipitated withdrawal results in rapidly
escalating and severe opioid withdrawal symptoms that require immediate treatment.103
Prescriber: A nurse practitioner, physician assistant, or physician licensed to prescribe medications and with the authority
to prescribe the medication under discussion. Note that state laws may vary with regard to prescribing authorities.
Provider: A physician, nurse practitioner, or physician assistant.
Psychiatric complications: Acute mental health signs and symptoms, such as psychosis, severe depression, and suicidal
ideation, that complicate withdrawal management.
Psychosis: An abnormal mental state involving significant problems with reality testing; characterized by serious
impairments or disruptions in the most fundamental higher brain functions—perception, cognition and cognitive
processing, and emotions or affect—as manifested in behavioral phenomena, such as delusions, hallucinations, and
significantly disorganized speech.104
Qualified health care professional: A physician, physician assistant, nurse, nurse practitioner, or another who by virtue of
their education, credentials, experience, and licensure can competently and legally execute the clinical activity at hand.
Qualified health care staff: All full-time, part-time, and per diem qualified health care professionals, as well as
administrative and support staff (e.g., health records administrators, laboratory technicians, nursing and medical
assistants, clerical workers), who are appropriately trained and, where required, credentialed, for the task at hand.
Qualified mental health care professional: A psychiatrist, psychologist, psychiatric social worker, psychiatric nurse, or
another who by their education, credentials, and experience are permitted by law to evaluate and care for the mental
health needs of patients for the task at hand.105
Responsible provider: An individual qualified and authorized to practice medicine (i.e., physician, nurse practitioner, or
physician assistant) who has the final authority at a given facility regarding clinical issues.
Screening: A brief, routine process designed to identify indicators, or “red flags,” for the presence of mental health,
substance use, or other issues that reflect an individual’s need for treatment.106
Sedative-hypnotics (sedatives): Drugs that depress the central nervous system, including benzodiazepines, barbiturates,
GHB, and Z-drugs.107
Standard drink: In the United States, roughly 14 grams of pure alcohol, which is found in 12 ounces of regular beer, 5
ounces of wine, or 1.5 ounces of distilled spirits.108
Standards of care: Treatment that is accepted by medical experts as a proper treatment for a certain medical condition
and is widely used by health care professionals.109
Stimulant: Substances that speed up the body’s systems, including prescription drugs (amphetamines, methylphenidate,
diet aids) and other illicitly used drugs, such as methamphetamine, cocaine, methcathinone, and other synthetic
cathinones commonly sold under the guise of “bath salts.”110

Stimulant use disorder: A substance use disorder involving stimulants.111
Substance use disorder: A cluster of cognitive, behavioral, and physiological symptoms indicating that an individual
continues to use alcohol, nicotine, and/or other drugs despite significant related problems. The Diagnostic and Statistical
Manual of Mental Disorders (DSM-5-TR) provides diagnostic criteria.112
Suicidal ideation: A range of contemplations of, wishes for, and preoccupations with death and suicide.113
Supportive care: Treatment to prevent, control, or relieve complications and side effects and to improve the patient’s
comfort, quality of life, and safety.114 It may include hydration, nutritional supplementation, management of electrolyte
abnormalities, and periodic clinical reevaluations, as clinically indicated.
Symptom-triggered dosing: An approach where patients receive medication only when symptoms cross a threshold
of severity.115
Taper: Gradual reduction of medications over time under the supervision of a qualified health care professional to
properly manage and substantively mitigate symptoms of withdrawal. Drugs that produce physiological dependence
(e.g., opiates, benzodiazepines) must be tapered to prevent a withdrawal syndrome.116, 117
Telehealth: Use of digital information and communication technologies, such as computers and mobile devices, to
access health care services remotely and manage health care.118
Titration: Monitoring response to dosage and adjusting accordingly to safely maximize the benefit of a medication.119
Transmucosal: Relating to, being, or supplying a medication that enters through or across a mucous membrane (as of
the mouth).120
Tremor: An uncontrollable and rhythmic shaking movement in one or more parts of the body due to muscle
contractions.121
Validated: Having demonstrated empirical evidence for reliability and validity.122
Well-trained: Having completed training designed and delivered by appropriate clinical professionals for the task at
hand and including the training recommendations described in Staffing and Staff Training.
Wernicke encephalopathy: A neurological disorder caused by a deficiency of vitamin B1 (thiamine). The principal
symptoms are confusion, oculomotor abnormalities (gaze palsy and nystagmus), and ataxia. The disorder is most
frequently associated with chronic alcoholism but is also found in cases of pernicious anemia, gastric cancer, and
malnutrition.123 (See Korsakoff syndrome)
Withdrawal management: Services to assist a patient’s withdrawal from substances. (Sometimes less accurately referred to
as “detoxification.” The distinction is that the liver detoxifies; qualified health care professionals manage withdrawal.)124
Withdrawal syndrome: The onset of a predictable constellation of signs and symptoms following the abrupt
discontinuation of, or rapid decrease in, dosage of a psychoactive substance.125
Z-drugs: Nonbenzodiazepine sedative-hypnotics (e.g., zaleplon (Sonata®), zolpidem (Ambien®), and zopiclone

(Imovane®) often prescribed to treat insomnia.126 Withdrawal symptoms are noted upon abrupt discontinuation of Z-drug
use, especially among patients with SUD.127

Appendix L: Acronym Glossary
AAAP American Academy of Addiction Psychiatry
ACA American Correctional Association
ACAAM American College of Academic Addiction Medicine
ACMT American College of Medical Toxicology
ACOG American College of Obstetricians and Gynecologists
AHP Advocates for Human Potential, Inc.
AJA American Jail Association
AOAAM American Osteopathic Academy of Addiction Medicine
ASAM American Society of Addiction Medicine
AUD Alcohol use disorder
BAC Blood alcohol concentration
BJA Bureau of Justice Assistance
BrAC Breath alcohol concentration
CAPTA Child Abuse Prevention and Treatment Act
CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised
COCHS Community Oriented Correctional Health Services
COPS Office of Community Oriented Policing Services
COSSUP BJA’s Comprehensive Opioid, Stimulant, and Substance Use Program
COWS Clinical Opiate Withdrawal Score

CPR Cardiopulmonary resuscitation
CRD Civil Rights Division
DEA U.S. Drug Enforcement Administration
EC Expert committee
EMS Emergency medical services
FASD Fetal alcohol spectrum disorder
FDA U.S. Food and Drug Administration
GHB Gamma-hydroxybutyric acid
HMA Health Management Associates

IV Intravenous
MCSA Major County Sheriffs of America
MOU Memorandum of understanding
NAATP National Association of Addiction Treatment Providers
NACo National Association of Counties
NCCHC National Commission on Correctional Health Care
NIAAA National Institute on Alcohol Abuse and Alcoholism
NIDA National Institute on Drug Abuse
NLM National Library of Medicine
NPG National Practice Guideline
NSA National Sheriffs’ Association
NSAID Nonsteroidal anti-inflammatory medication (drug)
OTP Opioid treatment program
OUD Opioid use disorder
PDMP Prescription Drug Monitoring Program
RAM RAND/UCLA Appropriateness Method
RCT Randomized clinical trial
SAMHSA Substance Abuse Mental Health Services Administration
SRLEEA Small & Rural Law Enforcement Executives Association
SUD Substance use disorder
TIP Treatment Improvement Protocol
VA U.S. Department of Veterans Affairs

Appendix M: Resources
To navigate to various sections of this resource list, click on the corresponding hyperlink.
Clinical Practice Studies

Legislation, Rules, and Regulations
Substances
Treatment and Medication
Reentry
Screening and Assessment
Suicide
Telehealth
Clinical Practice Studies

“Microinduction of Buprenorphine/Naloxone: A Review of the Literature”—review of existing literature to help clinicians
better understand the approaches to micro-dosing of buprenorphine in various clinical settings and populations.
(American Journal on Addictions)
“Review Article: Rapid Review of the Emergency Department-initiated Buprenorphine for Opioid Use Disorder”—
investigation of the effectiveness of initiating buprenorphine in the emergency department setting. (Emergency
Medicine Australasia)
Treatment for Pregnant People with Opioid Use Disorder in Jail—study focusing on jails, recognizing that these facilities
are embedded in communities and pregnant persons with opioid use disorder (OUD) entering jails need appropriate
care and linkages to services when returning to the community. (Advocacy and Research on Reproductive Wellness of
Incarcerated People at Johns Hopkins School of Medicine)
Legislation, Rules, and Regulations

Dying Inside: To End Deaths of Despair, Address the Crisis in Local Jails—the legal framework on the right to adequate
medical, mental health, and substance use disorder (SUD) care and treatment in jails. (O’Neill Institute for National and
Global Health Law)
Find Your Nurse Practice Act—online tool to locate each state’s Nurse Practice Act, as well as rules and regulations.
(National Council of State Boards of Nursing)
How to Use the DEA “72-Hour Emergency Rule” for Methadone in Jails—how jails’ physicians may use this rule
to continue methadone without interruption while the jail establishes a longer-term plan for continuation. (Health
Management Associates)

Managing Substance Withdrawal in Jails: A Legal Brief—the scope of challenge, overview of key legislation and court
cases related to substance withdrawal, and steps to create a comprehensive response for people with SUD. (Bureau of
Justice Assistance [BJA], National Institute of Corrections)

Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants—
comprehensive guidance for optimal management of pregnant and parenting people with OUD and their infants.
(Substance Abuse and Mental Health Services Administration [SAMHSA])
Opioid Use and Opioid Use Disorder in Pregnancy—recommendations for identification of and treatment for pregnant
persons with SUD. (The American College of Obstetricians and Gynecologists [ACOG])
Reproductive Health Care for Incarcerated Pregnant, Postpartum, and Nonpregnant Individuals—how obstetricians-
gynecologists and other practitioners can support efforts to improve health care for pregnant, postpartum, and non-
pregnant persons who are incarcerated. (ACOG)
Substance Abuse Reporting and Pregnancy: Role of the Obstetrician-Gynecologist—discussion of reporting requirements
related to SUD that an obstetrician-gynecologist should be aware of within their state. (ACOG)
Substance Use and Pregnancy – Part 1: Current State Policies on Mandatory Reporting and Implementing Plans of Self
Care to Support Pregnant Persons with Substance Use Disorders—examination of state-level policies supporting or
inhibiting pregnant and postpartum persons’ access to long-term recovery from OUD. (BJA’s Comprehensive Opioid,
Stimulant, and Substance Use Program [COSSUP])
Substance Use During Pregnancy and Family Care Plans—fact sheet on substance use during pregnancy and family
planning. (Legislative Analysis and Public Policy Association with funding from the Office of National Drug Control Policy)
Substances
Barbiturates—fact sheet on barbiturates. (Drug Enforcement Administration [DEA])
Benzodiazepines—description of benzodiazepines, including its licit and illicit uses. (DEA)
Chlordiazepoxide—description of chlordiazepoxide and its uses. (National Library of Medicine’s [NLM’s] MedlinePlus)
Clonazepam—description of clonazepam and its uses. (NLM’s Medline Plus)
Diazepam—description of diazepam and its uses. (NLM’s MedlinePlus)
Drug Fact Sheets—descriptions of various medications, as well as illicit drugs. (DEA)
Facts About Fentanyl—information about fentanyl. (DEA)
Gamma Hydroxybutyric Acid (GHB)—description of GHB, including its licit and illicit uses. (DEA)
Substance Use – Prescription Drugs—common medications that are misused and a list of “street names.” (NLM’s
MedlinePlus)

Treatment and Medication
Advisory: Addressing the Specific Needs of Women for Treatment of Substance Use Disorders—advisory for SUD
treatment for women. (SAMHSA)
The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management—evidence-based strategies and standards of
care for alcohol withdrawal management. (American Society of Addiction Medicine [ASAM])
Buprenorphine Practitioner Locator—listing of practitioners authorized to treat OUD with buprenorphine by state.
(SAMHSA)
Buprenorphine Quick Start Guide—fact sheet and checklist for initiating buprenorphine for prescribing medication for
the treatment of OUD. (SAMHSA)
FindTreatment.gov—resource for locating treatment providers. (SAMHSA)
“High-dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder”—
examination of the safety and tolerability of high-dose buprenorphine induction for patients with OUD presenting to an
ED. (JAMA Network)
Innovative Efforts to Distribute Naloxone to Justice-involved Populations—examples from the field, including naloxone
distribution via vending machines in county jails. (COSSUP)
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide—guidance on medications to treat AUD. (SAMHSA
and National Institute on Alcohol Abuse and Alcoholism [NIAAA])
Medication for the Treatment of Alcohol Use Disorder: Pocket Guide—assistance for clinicians in prescribing medications
to treat AUD. (SAMHSA and NIAAA)
Medication-assisted Treatment for Opioid Use Disorder in Jails and Prisons: A Planning & Implementation Toolkit—toolkit
intended to help correctional administrators and health care providers to plan and implement medication-assisted
treatment (MAT) programs within jails and prisons. (National Council for Behavioral Health, Vital Strategies)
Medications for Opioid Use Disorder for Healthcare and Addiction Professionals, Policymakers, Patients, and Families,
TIP 63—review of U.S. Food and Drug Administration-approved medications for opioid use disorder treatment and other
strategies and services needed to support people in recovery. (SAMHSA)
Medications to Treat Opioid Use Disorder Research Report: How Do Medications To Treat Opioid Use Disorder Work?—
discussion of how medications to treat OUD work. (National Institute on Drug Abuse [NIDA])
Myths and Facts About Medication-assisted Treatment—debunking of myths about MAT and falsehoods about its
provision in jails. (COSSUP)
Naloxone in Correctional Facilities for the Prevention of Opioid Overdose Deaths—position statement on the prevention
of opioid overdose deaths. (National Commission on Correctional Health Care [NCCHC])
A National Snapshot Update: Access to Medications for Opioid Use Disorder in U.S. Jails and Prisons—overview of
litigation, state legislation, and policies that had been adopted to increase access to MAT. (O’Neill Institute for National
and Global Health Law)

Opioid Treatment Program Directory—listing of opioid treatment programs by state. (SAMHSA)
Opioid Use Disorder Treatment in Correctional Settings—position statement on patient health records upon release.
(NCCHC)
Performance Measures for Medication-assisted Treatment in Correctional Settings: A Framework for Implementation—
framework for jail and prison administrators, program managers, medical staff in correctional settings, and reentry staff to
monitor MAT in correctional settings. (Legislative Analysis and Public Policy Association)
A Primer for Implementation of Overdose Education and Naloxone Distribution in Jails and Prisons—strategies for
developing, coordinating, monitoring, and evaluating jail and prison-based programs, as well as lessons learned from
two studies. (RTI International with funding from NIDA)
Standards for Opioid Treatment Programs—requirements for corrections-based opioid treatment programs seeking
accreditation. (NCCHC)
Substance Abuse Treatment: Addressing the Specific Needs of Women, TIP 51—guidance for providers in offering
treatment to women with SUD. (SAMHSA)
Treating Substance Use Disorder in Older Adults, TIP 26—guidance for providers and others to better understand how to
identify, manage, and prevent substance misuse among older adults. (SAMHSA)
Treatment for Stimulant Use Disorders, TIP 33—recommendations on treatment approaches, strategies for planning and
initiating treatment, as well as how to maximize treatment engagement and retention, and strategies for initiating and
maintaining abstinence. (SAMHSA)
Use of Medication-assisted Treatment for Opioid Use Disorder in Criminal Justice Settings—use of MAT for OUD in jails
and prisons and during the reentry process, providing an overview of policies and evidence-based practices reducing the
risk of overdose and relapse. (SAMHSA)
Reentry
Guidelines for Successful Transition of People with Mental or Substance Use Disorders from Jail and Prison:
Implementation Guide—behavioral health, correctional, and community stakeholders with implementation examples for
transitioning people with mental disorders or SUD from correctional settings into the community. (SAMHSA)
National Reentry Resource Center—primary source of reentry information and guidance. (BJA)
Optimizing Insurance Coverage for Individuals Postrelease—position statement on insurance coverage upon release.
(NCCHC)
Principles of Community-based Behavioral Health Services for Justice-involved Individuals: A Research-based Guide—
guidance for community-based behavioral health providers in their clinical and case management practice. (SAMHSA)
Sharing of Patient Health Records Upon Release from Incarceration—position statement on patient health records upon
release. (NCCHC)

Screening and Assessment
CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised)—commonly used withdrawal assessment
tool for alcohol. (ASAM)
COWS (Clinical Opiate Withdrawal Scale)—commonly used withdrawal assessment tool for opioids. (NIDA)
Screening and Assessment of Co-occurring Disorders in the Justice System—a wide range of evidence-based practices
for screening and assessment of people in the justice system who have co-occurring disorders. (SAMHSA)
Screening and Assessment Tools Chart—evidence-based screening tools by substance type, patient age, and
administration type. (NIDA)
Screening for Substance Use Disorders in Jails—frequently used screening instruments with descriptions of their purpose,
method administration, benefits, considerations, and cost/availability. (COSSUP)
Suicide
Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, Treatment Improvement Protocol (TIP) 50—
guidelines for working with adults with SUD. (SAMHSA)
Advisory: Addressing Suicidal Thoughts and Behaviors in Substance Use Treatment—guidance on identifying and
addressing suicidal thoughts and behaviors among individuals with SUD. (SAMHSA)
American Foundation for Suicide Prevention—voluntary health organization offering those affected by suicide a
nationwide community informed by research, education, and advocacy. (American Foundation for Suicide Prevention)
APA Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts—recommendations for the
treatment of depressive disorders (including major depression, subsyndromal depression, and persistent depressive
disorder). (American Psychological Association)
Ask Suicide-Screening Questions (ASQ) Toolkit—screening tool for suicide risk. (National Institute of Mental Health)
Suicide Prevention Resource Center—federally supported resource center devoted to advancing the implementation of
the National Strategy for Suicide Prevention. (SAMHSA)
Suicide Prevention Resource Guide: National Response Plan for Suicide Prevention in Corrections—resource on
preventing suicide in corrections facilities. (NCCHC, American Foundation for Suicide Prevention)

Telehealth
Telehealth Implementation Support Tool—an online support tool intended to be completed in approximately 20 minutes
by a jail administrator, who may need input from other stakeholders. (COSSUP)
“Telemedicine,” from the COVID-19 Information web page—guidance on how telemedicine can be used, including the
DEA policy on the use of telephone evaluations to initiate buprenorphine. (DEA)
Using Telehealth for Behavioral Health in the Criminal Justice System—a brief on telehealth services and its benefits to
the criminal justice system as an innovative strategy for intervention and treatment of OUD. (COSSUP)

Endnotes
The White House, Executive Office of the President, Office of National Drug Control Policy, 2022, National Drug
1
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Drug-Control-2022Strategy.pdf.
2
Bronson, Jennifer, Jessica Stroop, Stephanie Zimmer, and Marcus Berzofsky, June 2017, Drug Use, Dependence, and
Abuse Among State Prisoners and Jail Confined Persons, 2007–2009, Washington, DC: U.S. Department of Justice,
Bureau of Justice Statistics: 3, NCJ 250546, retrieved February 9, 2022 from https://bjs.ojp.gov/content/pub/pdf/
dudaspji0709.pdf.
3
Fiscella, Kevin, Margaret Noonan, Susan H. Leonard, Subrina Farah, Mechelle Sanders, Sarah E. Wakeman, and Jukka
Savolainen, 2020, “Drug- and Alcohol-Associated Deaths in U.S. Jails,” Journal of Correctional Health Care 26(2):
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E. Ann Carson, December 2021, Mortality in Local Jails, 2000–2019 – Statistical Tables, Washington, DC: U.S.
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content/pub/pdf/mlj0019st.pdf.
See note 3 above, Fiscella et al., “Drug- and Alcohol-Associated Deaths in U.S. Jails.”
5
6
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7
Moore, Kelly E., Lindsay Oberleitner, Kathryn M.Z. Smith, Kathleen Maurer, and Sherry A. McKee, 2018, “Feasibility
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ADM.0000000000000381.
8
Fitch, Kathryn, Steven J. Bernstein, Maria Dolores Aguilar, Bernard Burnand, Juan Ramon LaCalle, Pablo Lazaro, Mirjam
van het Loo, Joseph McDonnell, Janneke Vader, and James P. Kahan, 2001, The RAND/UCLA Appropriateness Method
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FINAL.pdf.
Binswanger, Ingrid A., Marc F. Stern, Richard A. Deyo, Patrick J. Heagerty, Allen Cheadle, Joann G. Elmore, and
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Medicine (356): 157–165, retrieved February 3, 2023 from https://www.nejm.org/doi/full/10.1056/nejmsa064115.

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MedlinePlus, n.d., Alcohol Withdrawal, Bethesda, MD: National Library of Medicine, National Institutes of Health,
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Withdrawal Management, 5.
MedlinePlus, n.d., Wernicke-Korsakoff Syndrome, Bethesda, MD: National Library of Medicine, National Institutes
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23
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47
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Guidelines For Managing Substance Withdrawal in Jails

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Office of Justice Programs

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American Correctional Association (ACA)

American Society of Addiction Medicine (ASAM)

American Jail Association (AJA)

Major County Sheriffs of America (MCSA)

National Association of Counties (NACo)

National Commission on Correctional Health Care (NCCHC)

Small & Rural Law Enforcement Executives Association (SRLEEA)

Guidelines for Managing Substance Withdrawal in Jails i

• Chief Deputy Jeff Clark, M.J.A. • Wendy Habert, M.B.A., PHR,

• Carrie Hill, Esq. • Jim Martin, M.P.S.A., CCHP

• Shannon Robinson, M.D. • Jaime Shimkus, CCHP

• Sandra Springer, M.D. • Kim Sterling, M.B.A.

• Marc F. Stern, M.D., M.P.H. • Claire Wolfe, M.A., M.P.H., CCHP

• Chief Deputy Geoff Stobart

Guidelines for Managing Substance Withdrawal in Jails v

Development of the Guidelines...........................................................................................................................................2

The Withdrawal Management Process......................................................................................................................... 5

Onsite Withdrawal Management Versus External Transfer.................................................................................................6

Screening To Flag Withdrawal Risk......................................................................................................................................7

Monitoring for Withdrawal Signs and Symptoms................................................................................................................9

Clinical Assessment and Diagnosis....................................................................................................................................11

Withdrawal Management by Qualified Health Care Professionals....................................................................................14

Monitoring Patients During Withdrawal Management......................................................................................................15

Staffing and Staff Training..................................................................................................................................................17

Guidelines for Managing Substance Withdrawal in Jails vii

Pregnancy and Postpartum................................................................................................................................................21

Monitoring for Withdrawal Signs and Symptoms..............................................................................................................26

Clinical Assessment and Diagnosis....................................................................................................................................26

Withdrawal Management by Qualified Health Care Professionals....................................................................................27

Monitoring Patients During Withdrawal Management......................................................................................................27

Pregnancy and Postpartum................................................................................................................................................31

Polysubstance Use Disorder..............................................................................................................................................33

Monitoring for Withdrawal Signs and Symptoms..............................................................................................................35

Clinical Assessment and Diagnosis....................................................................................................................................36

Monitoring Patients During Withdrawal Management......................................................................................................37

Pregnancy and Postpartum................................................................................................................................................39

viii BUREAU OF JUSTICE ASSISTANCE

Monitoring for Withdrawal Signs and Symptoms..............................................................................................................42

Clinical Assessment and Diagnosis....................................................................................................................................43

Monitoring Patients During Withdrawal Management......................................................................................................50

Pregnancy and Postpartum................................................................................................................................................51

Monitoring for Withdrawal Signs and Symptoms..............................................................................................................56

Clinical Assessment and Diagnosis....................................................................................................................................56

Monitoring Patients During Withdrawal Management......................................................................................................57

Pregnancy and Postpartum................................................................................................................................................60

Appendix A: Development Team............................................................................................................................... 63

Expert Committee ............................................................................................................................................................63

Federal Project Champions................................................................................................................................................64

Technical Support Team.....................................................................................................................................................64

Appendix B: Full Methodology.................................................................................................................................. 67

Overview of Approach ......................................................................................................................................................67

Guidelines for Managing Substance Withdrawal in Jails ix

Task 2: Identification of Draft Statements and Appropriateness/Feasibility Rating .........................................................70

Appendix C: Preferred Terminology.......................................................................................................................... 73