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!
Treatment!of!adolescents!with!substance!abuse!disorders!
!
Author&
Below&please&list&the&author(s)&of&this&resource."
!
Ken!C.!Winters!
!
Citation&
Below&please&cite&this&resource&in&APA&style.&For&guidance&on&citation&format,&please&visit&
http://owl.english.purdue.edu/owl/resource/560/01/&
!
Winters,!K.C.!(1999).!Treatment!of!adolescents!with!substance!abuse!disorders.!Treatment"
" Improvement"Protocol"(TIP)"Series"32.!Retrieved!from!
! http://radar.boisestate.edu/pdfs/TIP32.pdf!
!
!
Summary&
Below&please&provide&a&brief&summary&of&this&resource.&If&an&abstract&is&available,&feel&free&to©&and&paste&it&here.&
!
Treatment!Improvement!Protocols!(TIPs)!are!best!practice!guidelines!for!the!treatment!of!
substance!use!disorders,!provided!as!a!service!of!the!Substance!Abuse!and!Mental!Health!
Services!Administration's!(SAMHSA)!Center!for!Substance!Abuse!Treatment!(CSAT).!CSAT's!
Office!of!Evaluation,!Scientific!Analysis!and!Synthesis!draws!on!the!experience!and!
knowledge!of!clinical,!research,!and!administrative!experts!to!produce!the!TIPs,!which!are!
distributed!to!a!growing!number!of!facilities!and!individuals!across!the!country.!The!
audience!for!the!TIPs!is!expanding!beyond!public!and!private!treatment!facilities!for!
substance!use!disorders!as!substance!use!disorders!are!increasingly!recognized!as!a!major!
problem.!!
! "
Treatment of Adolescents With Substance
Use Disorders
Treatment Improvement Protocol (TIP) Series
32
Ken C. Winters, Ph.D.
Revision Consensus Panel Chair
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857
DHHS Publication No. (SMA) 99-3283
Printed 1999
Table of Contents
[Front Matter]
Executive Summary and Recommendations
Chapter 1--Substance Use Among Adolescents
Chapter 2 -- Tailoring Treatment to the Adolescent's Problem
Chapter 3 -- General Program Characteristics
Chapter 4 -- Twelve-Step-Based Programs
Chapter 5 -- Therapeutic Communities
Chapter 6 -- Family Therapy
Chapter 7 -- Youths With Distinctive Treatment Needs
Chapter 8 -- Legal and Ethical Issues
Endnotes
Appendix A -- Bibliography
Appendix B -- Medical Management of Drug Intoxication and Withd...
Appendix C --Field Reviewers
[Figures]
KenC.Winters,Ph.D.
RevisionConsensusPanelChair
U.S.DEPARTMENTOFHEALTHANDHUMANSERVICES
PublicHealthService
SubstanceAbuseandMentalHealthServicesAdministration
CenterforSubstanceAbuseTreatment
RockwallII,5600FishersLane
Rockville,MD20857
DHHSPublicationNo.(SMA)993283
Printed1999
[Disclaimer]
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical
assistance program. All material appearing in this volume except that taken directly from
copyrighted sources is in the public domain and may be reproduced or copied without permission
from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for
Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number 270-95-0013 with The CDM Group, Inc.
(CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Rose
M. Urban, M.S.W., J.D., C.S.A.C., served as the CDM TIPs project director. Other CDM TIPs
personnel included Y-Lang Nguyen, production/copy editor, Raquel Ingraham, M.S., project
manager, Virginia Vitzthum, former managing editor, Mary Smolenski, Ed.D., C.R.N.P., former
project director, and MaryLou Leonard, former project manager.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect
the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services
(DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions
or for particular instruments or software that may be described in this document is intended or
should be inferred. The guidelines proffered in this document should not be considered as
substitutes for individualized client care and treatment decisions.
WhatIsaTIP?
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of
substance use disorders, provided as a service of the Substance Abuse and Mental Health
Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT). CSAT's
Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge
of clinical, research, and administrative experts to produce the TIPs, which are distributed to a
growing number of facilities and individuals across the country. The audience for the TIPs is
expanding beyond public and private treatment facilities for substance use disorders as substance
use disorders are increasingly recognized as a major problem.
The TIPs Editorial Advisory Board, a distinguished group of substance use disorder experts and
professionals in such related fields as primary care, mental health, and social services, works
with the State alcohol and drug abuse directors to generate topics for the TIPs based on the field's
current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national
organizations to a Resource Panel that recommends specific areas of focus as well as resources
that should be considered in developing the content of the TIP. Then recommendations are
communicated to a Consensus Panel composed of non-Federal experts on the topic who have
been nominated by their peers. This Panel participates in a series of discussions; the information
and recommendations on which they reach consensus form the foundation of the TIP. The
members of each Consensus Panel represent treatment programs for substance use disorders,
hospitals, community health centers, counseling programs, criminal justice and child welfare
agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines
mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes
recommended by these field reviewers have been incorporated, the TIP is prepared for
publication, in print and online. The TIPs can be accessed via the Internet on the National
Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic
media also means that the TIPs can be updated more easily so that they continue to provide the
field with state-of-the-art information.
Although each TIP strives to include an evidence base for the practices it recommends, CSAT
recognizes that the field of substance use disorder treatment is evolving, and published research
frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to
convey "front-line" information quickly but responsibly. For this reason, recommendations
proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there
is research to support a particular approach, citations are provided.
This TIP, Treatment of Adolescents With Substance Use Disorders, updates TIP 4, published in
1993, and presents information on substance use disorder treatment for adolescent clients.
Adolescents differ from adults both physiologically and emotionally as they make the transition
from child to adult and, thus, require treatment adapted to their needs. The onset of substance use
is occurring at younger ages, resulting in more adolescents entering treatment for substance use
disorders than has been observed in the past. In order to treat this population effectively,
treatment providers must address the issues that play significant roles in an adolescent's life, such
as cognitive, emotional, physical, social, and moral development, and family and peer
environment. This TIP focuses on ways to specialize treatment for adolescents, as well as on
common and effective program components and approaches being used today.
Chapter 1 details the scope and complexity of the problem; Chapter 2 presents factors to be
considered when making treatment decisions; and Chapter 3 discusses successful program
components. Chapters 4, 5, and 6 describe the treatment approaches used in 12-Step-based
programs, therapeutic communities, and family therapy respectively. Chapter 7 discusses
adolescents with distinctive treatment needs, such as those involved with the juvenile justice
system. An explanation of legal issues concerning Federal and State confidentiality laws appears
in Chapter 8. Appendix B is a table on the medical management of substance intoxication and
withdrawal, which will appear in a forthcoming publication.
Other TIPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug
Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800)
487-4889.
EditorialAdvisoryBoard
KarenAllen,Ph.D.,R.N.,C.A.R.N.
PresidentoftheNationalNursesSocietyonAddictions
AssociateProfessor
DepartmentofPsychiatry,CommunityHealth,andAdultPrimaryCare
UniversityofMaryland
SchoolofNursing
Baltimore,Maryland
RichardL.Brown,M.D.,M.P.H.
AssociateProfessor
DepartmentofFamilyMedicine
UniversityofWisconsinSchoolofMedicine
Madison,Wisconsin
DorynneCzechowicz,M.D.
AssociateDirector
Medical/ProfessionalAffairs
TreatmentResearchBranch
DivisionofClinicalandServicesResearch
NationalInstituteonDrugAbuse
Rockville,Maryland
LindaS.Foley,M.A.
FormerDirector
ProjectforAddictionCounselorTraining
NationalAssociationofStateAlcoholandDrugDirectors
Washington,D.C.
WaydeA.Glover,M.I.S.,N.C.A.C.II
Director
CommonwealthAddictionsConsultantsandTrainers
Richmond,Virginia
PedroJ.Greer,M.D.
AssistantDeanforHomelessEducation
UniversityofMiamiSchoolofMedicine
Miami,Florida
ThomasW.Hester,M.D.
FormerStateDirector
SubstanceAbuseServices
DivisionofMentalHealth,MentalRetardationandSubstanceAbuse
GeorgiaDepartmentofHumanResources
Atlanta,Georgia
GilHill
Director
OfficeofSubstanceAbuse
AmericanPsychologicalAssociation
Washington,D.C.
DouglasB.Kamerow,M.D.,M.P.H.
Director
OfficeoftheForumforQualityandEffectivenessinHealthCare
AgencyforHealthCarePolicyandResearch
Rockville,Maryland
StephenW.Long
Director
OfficeofPolicyAnalysis
NationalInstituteonAlcoholAbuseandAlcoholism
Rockville,Maryland
RichardA.Rawson,Ph.D.
ExecutiveDirector
MatrixCenterandMatrixInstituteonAddiction
DeputyDirector,UCLAAddictionMedicineServices
LosAngeles,California
EllenA.Renz,Ph.D.
FormerVicePresidentofClinicalSystems
MEDCOBehavioralCareCorporation
Kamuela,Hawaii
RichardK.Ries,M.D.
DirectorandAssociateProfessor
OutpatientMentalHealthServicesandDualDisorderPrograms
HarborviewMedicalCenter
Seattle,Washington
SidneyH.Schnoll,M.D.,Ph.D.
Chairman
DivisionofSubstanceAbuseMedicine
MedicalCollegeofVirginia
Richmond,Virginia
ConsensusPanel
199798RevisionConsensusPanelChair
KenC.Winters,Ph.D.
AssociateProfessor
DepartmentofPsychiatry
UniversityofMinnesotaHospitalandClinic
Minneapolis,Minnesota
199798RevisionConsensusPanel
GayleA.Dakof,Ph.D.
ResearchAssistantProfessor
CenterforFamilyStudies
DepartmentofPsychiatryandBehavioralSciences
UniversityofMiamiSchoolofMedicine
Miami,Florida
RichardDembo,Ph.D.
ProfessorofCriminology
UniversityofSouthFlorida
Tampa,Florida
NancyJainchill,Ph.D.
SeniorPrincipalInvestigator
CenterforTherapeuticCommunityResearch
NationalDevelopmentandResearchInstitutes
NewYork,NewYork
MicheleD.Kipke,Ph.D.
Director
BoardonChildren,Youth,andFamilies
NationalResearchCouncil
InstituteofMedicine
Washington,D.C.
JohnR.Knight,M.D.
AssociateDirectorforMedicalEducation
DivisiononAddictions
HarvardMedicalSchool
AssistantinMedicine
Children'sHospital
Boston,Massachusetts
HowardLiddle,Ed.D.
ProfessorandDirector
CenterforTreatmentResearchonAdolescentDrugAbuse
DepartmentofPsychiatryandBehavioralSciences
UniversityofMiamiSchoolofMedicine
Miami,Florida
199293ConsensusPanelChair
S.KennethSchonberg
Director
DivisionofAdolescentMedicine
MontefioreMedicalCenter
Bronx,NewYork
199293WorkgroupLeaders
GeraldD.Shulman
ExecutiveDirector
MountainWoodTreatmentCenter
Charlottesville,Virginia
SusanWallace
CaritasHouse
Pawtucket,RhodeIsland
KenC.Winters,Ph.D.
Director
CenterforAdolescentSubstanceAbuse
UniversityofMinnesota,
DivisionofAdolescentHealth
Minneapolis,Minnesota
JohnZachariah
RegionalAdministrator
AmericanCorrectionalAssociation
Laurel,Maryland
199293WorkgroupMembers
BruceAbel,D.S.W.,L.C.S.W.
LookingGlassCounselingCenter
Eugene,Oregon
DrewAlexander,M.D.
AdolescentHealth
Dallas,Texas
TerryBeartusk
ExecutiveDirector
ThunderChildTreatmentCenter
Sheridan,Wyoming
CherrieBoyer,Ph.D.
DepartmentofPediatrics
UniversityofCalifornia
SanFrancisco,California
PeterCohen,M.D.
MedicalDirector
ChildrenandAdolescentsPrograms
Rockville,Maryland
RichardDembo,Ph.D.
ProfessorofCriminology
UniversityofSouthFlorida
Tampa,Florida
ElizabethCannonDuncan
SouthCarolinaCommissiononAlcoholandDrugAbuseTreatment
Columbia,SouthCarolina
GaryGiron
ExecutiveDirector
LaNeuveVida
SantaFe,NewMexico
RaymondL.Hilton,Ed.D.
AssistantSuperintendent
DepartmentofChildrenandYouthServices
LongLaneSchool
Middleton,Connecticut
MaryJaneSalsbery,R.N.,C.C.D.N.
JohnsonCountyAdolescentCenterforTreatment
Olathe,Kansas
BarbaraZugor
ExecutiveDirector
TASC,Inc.
Phoenix,Arizona
Foreword
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve
treatment of substance use disorders by providing best practices guidance to clinicians, program
administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and
health services research findings, demonstration experience, and implementation requirements. A
panel of non-Federal clinical researchers, clinicians, program administrators, and patient
advocates debates and discusses their particular area of expertise until they reach a consensus on
best practices. This panel's work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly
participatory process have bridged the gap between the promise of research and the needs of
practicing clinicians and administrators. We are grateful to all who have joined with us to
contribute to advances in the substance use disorder treatment field.
NelbaChavez,Ph.D.
Administrator
SubstanceAbuseandMentalHealthServicesAdministration
H.WestleyClark,M.D.,J.D.,M.P.H.,CAS,FASAM
Director
CenterforSubstanceAbuseTreatment
SubstanceAbuseandMentalHealthServicesAdministration
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1ThischapterwaswrittenfortheRevisionPanelbyMargaretK.Brooks,Esq.,Montclair,NewJersey.
2Anadultwith"decisionalcapacity"isonewhoisabletounderstandanexplanationofherdiagnosis,
prognosis,andchoicesoftreatment,aswellastheirrisksandbenefits,andlikelyoutcomeshould
treatmentberefused.
3InStateswhereparentalconsentisnotrequiredfortreatment,theFederalconfidentialityregulations
permitaprogramtowithholdservicesiftheminorwillnotauthorizeadisclosurethattheprogram
needsinordertoobtainfinancialreimbursementforthatminor'streatment.Theregulationsadda
warning,however,thatsuchactionmightviolateaStateorlocallaw(_2.14(b)).
4ProgramstaffmayneedtrainingaboutwhattheState'schildabuseandneglectlawsrequire,including
whatconditionsareconsideredreportable.Seethediscussionofchildabusereporting.
5Ofcourse,aprovidermayturnanadolescentawayforclinicalreasons,thatis,becauseithas
determinedthatnotreatmentisneededorthatthetreatmentitoffersisinappropriateforthe
particularadolescent.Inthiscase,theprogrammightwanttomakeareferraltoanothertypeof
counselingserviceortoanothersubstanceusedisordertreatmentprogram.Theprocedureformakinga
referralisdiscussedinsection2.
6Citationsintheform"_2..."refertospecificsectionsof42CodeofFederalRegulations(C.F.R.)Part2.
7Onlyadolescentswhohave"appliedfororreceived"servicesfromaprogramareprotected.Ifan
adolescenthasnotyetbeenevaluatedorcounseledbyaprogramandhasnothimselfsoughthelpfrom
theprogram,theprogramisfreetodiscusstheadolescent'ssubstanceusedisorderswithothers,
althoughitwouldnotbewisetodoso.But,fromthetimetheadolescentappliesforservicesorthe
programfirstconductsanevaluationorbeginstocounseltheyouth,theFederalregulationsgovern.
8Note,however,thatnoinformationthatisobtainedfromaprogram(eveniftheclientconsents)may
beusedinacriminalinvestigationorprosecutionofaclientunlessacourtorderhasbeenissuedunder
thespecialcircumstancessetforthin_2.65.42U.S.C._290dd2(c);42C.F.R._2.12(a),(d).
9AlthoughtherulesconcerningCJSconsentprobablyapplytoproceedingsinjuvenilecourtinvolving
actsthat,ifcommittedbyanadult,wouldbeacrime,thereappeartobenocasesonpoint.Itisless
likelythatthespecialCJSconsentruleswouldapplywhenanadolescentisadjudicated(foundtobe)in
needofspecialsupervision(e.g.,"personsinneedofsupervision"),butnotguiltyofacriminalact.
10Ifanattorneyisnotimmediatelyavailable,andsomeonewantsinformationaboutchildabuseand
neglectruleswithinaparticularState,contactthesocialserviceorchildwelfareagencyforthatarea.
Nationally,theChildWelfareLeagueofAmericacanalsobecalledat2026382952.Definitionsofterms
canalsobeaccessedontheInternet.Statestatutedefinitionsarelocatedat
http://www.calib.com/nccanch/statutes.htm.Federaldefinitions,whichappearintheChildAbuse
PreventionandTreatmentAct(CAPTA),42U.S.C._5106g,areavailableontheInternetat
http://www.calib.com/nccanch/pubs/whatis.htm
11Forinformationabouthowtodealwithcommunicationswithlawyers,lawenforcementofficialsand
subpoenas,seeTIP24,AGuidetoSubstanceAbuseServicesforPrimaryCareClinicians,(CSAT,1997),pp.
111112.Forinformationaboutdealingwithsearchandarrestwarrants,seeTIP19,Detoxificationfrom
AlcoholandOtherDrugs(CSAT,1995c),pp.8384.Additionalinformationaboutdealingwithsubpoenas
appearsinConfidentiality:AGuidetotheFederalLawsandRegulations,(NewYork:LegalActionCenter,
1995ed.).
12However,iftheinformationisbeingsoughttoinvestigateorprosecuteaclientforacrime,onlythe
programneedbenotified(_2.65);andiftheinformationissoughttoinvestigateorprosecutethe
program,nopriornoticeatallisrequired(_2.66).
13Outcomeevaluationthatassessesclients'behavioratsettimesaftercompletionoftreatment(the
importanceofwhichismentionedinChapter2)posesparticularproblemsundertheFederal
regulations.Foradiscussionofthisissueandamorecompleteexplanationoftherequirementsof
__2.52and2.53,seeTIP14,DevelopingStateOutcomesMonitoringSystemsforAlcoholandOtherDrug
AbuseTreatment(CSAT,1995a),pp.5859.
14Computerizationofrecordsgreatlycomplicateseffortstoensuresecurity.Forabriefdiscussionof
someoftheissuescomputerizationraises,seeTIP23,TreatmentDrugCourts:IntegratingSubstance
AbuseTreatmentWithLegalCaseProcessing(CSAT,1996),pp.5253.
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Selfreportedexperiencesofphysicalandsexualabuseamongrunawayyouths.Perspectivesin
PsychiatricCare30:2328,1994.
Weiss,G.,andHechtman,L.T.
HyperactiveChildrenGrownUp:AD/HDinChildren,Adolescents,andAdults,2nded.NewYork:
GuilfordPress,1993.
Wexler,H.K.;DeLeon,G.;Thomas,G.;Kressel,D.;andPeters,J.
TheAmityprisonTCevaluation:Reincarcerationoutcomes.JournalofCriminalandJustice
Behavior,inpress.
Widom,C.S.
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eds.AdolescentProblemBehaviors:IssuesandResearch.Hillsdale,NJ:LawrenceErlbaum,1994.
pp.127164.
Wilens,T.E.;Biederman,J.;Spencer,T.J.;andFrances,R.J.
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Windle,M.
Substanceuseandabuseamongadolescentrunaways:Afouryearfollowupstudy.Journalof
YouthandAdolescence18:331344,1989.
Windle,M.,andWindle,R.
Thecontinuityofbehavioralexpressionamongdisinhibitedandinhibitedchildhoodsubtypes.
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Theroleofpsychosocialfactorsasdeterminantsofdrugabuseamongtreatmentyouths.Journal
ofChildandAdolescentSubstanceAbuse,inpress.
Winters,K.C.,andSchiks,M.
Assessmentandtreatmentofadolescentchemicaldependency.In:Keller,P.,ed.Innovationsin
ClinicalPractice:ASourceBook.Vol.8.Sarasota,FL:ProfessionalResourceExchange,1989.pp.
213228.
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Chronic:
flashbacks
Pathological:
panic,paranoia,
psychosis
Reassuranceand
observation
(For
anticholinergics,
i.e.,jimsonweed,
nightshade,
symptomsare
moresevereand
mayrequire
gastriclavage,
benzodiazepine
sedation,and
hospitalization.)
Discontinuationof
use
Psychosis:close
observationina
quietroom.
benzodiazepines
(Lorazepam15
mg.PO).Useof
neuroleptic
medicationis
controversial.
Psychological Reassurance
MiscellaneousInformation:PCPmaybesprinkledonmarijuanaandsmoked.Exposurecanthusoccur
withouttheuser'sknowledge.
D.Inhalants
D.Inhalants
Names/Preparations Intoxication Withdrawal
Signsand
Symptoms
Treatment Signsand
Symptoms
Treatment
NitrousOxide,
laughinggas,
whippets
AmylNitrite,
poppers,snappers
ButylNitrate,
rush,bullet,climax
Chlorohydrocarbons
aerosolspraycans
Hydrocarbons,
gasoline,glue,
solvents,Whiteout
(typewriter
correctionfluid)
LeadedGasoline(not
inUS)
Acute:euphoria,
disorientation,
sedation,
conjunctival
injection,acute
toxicitytoCNS,
liver,kidneys
Nitrates:sudden
hypoxemia,
hypotension
Chronic:
peripheralnerve,
CNS,liver,and
kidneydamage
Pathological:
cardiac
arrhythmiaand
arrest
Symptomatic
medical
treatments
Discontinuationof
use,supportive
therapies(dialysis,
etc.)
Plumbism:
Chelationtherapy
Resuscitation,
hospitalization
Psychological
Physiological
unknown
Reassurance,
support
MiscellaneousInformation:Nitrousoxideissometimessoldatrockconcertsinsideballoons.Nitrate
compoundshavebeenmostpopularamonggaymen,allegedlytoenhancesexualexperiences.The
volatilehydrocarboncompoundsarefavoredbyyoungeradolescentsandpopularinsomeLatin
Americancountries,onNativeAmericanreservations,andinLatinocommunitieswithintheUnited
States.
E.Stimulants
E.Stimulants
Names/Preparations Intoxication Withdrawal
Signsand
Symptoms
Treatment Signsand
Symptoms
Treatment
Cocaine
Coke,Snow,Flake,
Blow,NoseCandy
Crack
Freebase,Rocks
Amphetamines
Speed,Black
Beauties
Methamphetamine
Crank,CrystalMeth,
Ice
Methylphenidate
Ritalin
Pemoline
Cylert
RxDietPills
Didrex,Tenuate,
Ionamin,Sanorex,
etc.
"Legalspeed"
OTCdietorstay
awakepills
Acute:
exhilaration,
euphoria,
restlessness,
irritability,
insomnia,
pupillary
dilatation,
tachycardia,
arrhythmia,chest
pain,
hypertension,
anorexia,
hyperpyrexia,
hyperreflexia
Chronic:(if
snorting:inflamed
nasalmucosa,
septalerosionor
perforation)
confusion,
sensory
hallucinations,
paranoia,
depression
Pathological:
suddencardiac
arrest,
hypertensive
crisis,seizures
Reassuranceand
observation
Symptomaticcare
Agitation:high
dose
benzodiazepines
(Diazepam1025
mg)
Tachycardia,HTN:
(controversial,see
below)
Hyperthermia:
externalcooling
Discontinuationof
use,symptomatic
treatment/care.
Psychosis:
Neuroleptic
medication
Resuscitation,
hospitalization
HTNcrisis:beta
blockers,
Phentolamine,
Nitroprusside
Seizures:IV
Diazepam,(see
alcoholsection
above),or
Phenytoin1520
mg/kgslowIV
pushwithcardiac
monitor
Chronicusers:
severedepression
with
suicidal/homicidal
ideation,
exhaustion,
prolongedsleep,
voraciousappetite
Closeobservation,
reassurance;
symptoms
disappearin34
days
MiscellaneousInformation:Whileuseofcocaineandcrackhasdeclinedsomewhatinrecentyears,
amphetamineshavebecomemorepopular.Methamphetamineismorecommonlyavailablein
California,theWest,andSouthwest.WiththeincreasedpublicawarenessofAD/HDandthe
popularityofstimulantmedicationstotreatit,Ritalinhasnowbecomeadrugofabuseamongsome
adolescents.Itcanbegroundupand"snorted,"andhasbeenimplicatedinseveralreportsofsudden
cardiacarrestanddeath.Socalled"legalspeed,"OTCpreparationswhichareavailableinpharmacies
andthroughmailorderhouses,cancausetoxicitysimilartomorepotentstimulantswhentakenin
highdoses.
F.Depressants
F.Depressants
Names/Preparations Intoxication Withdrawal
Signsand
Symptoms
Treatment Signsand
Symptoms
Treatment
Benzodiapines:
Valium,"V's,"
Librium,Serax,
Klonopin,Tranxene,
Xanax,Halcion,
Rohypnol,"Ruffies"
Barbiturates:
Nembutal,Seconal,
Amytal,Tuinal,
downers,barbs,blue
devils,reddevils,
yellows,yellow
jackets
Methaqualone:
Quaaludes,ludes,
sopors
MildMod:CNS
sedation,pupillary
constriction,
disorientation,
slurredspeech,
staggeringgait
Severe:
Respiratory
depression,
hypothermia,
coma,death
Pathological:
paradoxical
disinhibition,
hyperexcitability
Observationand
supportivecare,
protectairway,
positiononsideto
avoidaspiration
AcuteOD:Gastric
lavage.
Supportive:
ventilator,
warmingblanket,
ICUcare
Symptomspassin
amatterofhours;
physicalrestraint,
lowdose
benzodiazepine
rarelyneeded
MildMod:
restlessness,
anxiety,agitation,
tremor,
abdominal
cramps,nausea,
vomiting,
hyperreflexia,
hypertension,
headache,
insomnia
Severe:seizures,
delirium,
hyperpyrexia,
hallucinations,
death
Gradualreduction
ofthedrugof
dependency,or
Phenobarbital
substitution
(calculate
phenobarbital
equivalentofdaily
dose,orgive34
mg/kg/day
dividedbyq8h)
withgradual
taper.Orchange
shortacting
benzodiazepineto
longeracting
benzodiazepine
andthentaper
Seizures:
Diazepam
Hallucinations:
Haloperidol
(seealcohol
sectionabovefor
doses)
MiscellaneousInformation:Thesecompoundsareallsimilartoalcoholineffectandhighlyaddictive.
Withdrawalsymptomsaresevereandmaybegin1216hoursafterlastdoseormaybedelayedforup
toaweek.
G.Narcotics
G.Narcotics
Names/Preparations Intoxication Withdrawal
Signsand
Symptoms
Treatment Signsand
Symptoms
Treatment
Heroin,
smack,horse,junk,
brownsugar,BigH,
mud
Opium
RxNarcotics
Morphine,
Meperidine
Fentanyl,
Oxycodone,
Hydrocodone,
Codeine
Darvon,etc.
Acute:Euphoria,
pupillary
constriction,
depressionof
respirationsand
gagreflex,
bradycardia,
hypotension,
constipation
Chronic:
complicationsof
IVuseinclude
HepatitisB,
HIV/AIDS,SBE,
brainabscesses
Pathological:
AcuteODmay
causerespiratory
arrestanddeath
Airwayprotection,
judicioususeof
naloxone
Discontinuationof
use,targeted
medicalcarefor
infectious
complications
Intubationand
ventilation,
naloxone(IV,IM,
SC,ETT):children
<20kg:
0.1mg/kg/dose
q23hrs.
children>20kg:
25mg/dose
Chronicusers:
restlessness,
lacrimation,
yawning,pupillary
dilatation,
rhinorrhea,
sniffing,sneezing,
sweating,flushing,
tachycardia,
hypertension,
musclecramps,
abdominal
cramps,nausea,
vomiting,diarrhea
Acute
detoxification:
Methadone(PO)
Children:0.7
mg/kg/day
dividedbyq46
hrs.,oradult30
40mg./dayin34
divideddoses,
with5mg/day
taper.
Clonidine(PO)
Children:57
mcg/kg/day
dividedbyq612
hrs.(max=0.9
mg/day)
Adult:0.1mg.test
dose,check
posturalBPs.If
stable,0.10.2mg
POq46hrs.
Longterm
treatment:
Longterm
therapeutic
support.
Methadoneor
LAAM
maintenance
(specializedclinics
only)
MiscellaneousInformation:Individualswhoabusenarcoticsseldomseektreatmentforintoxication.
TheyaremoreoftenfoundsemicomatoseandbroughttothehospitalbyfriendsortheEMSfor
treatment.Whentreatinganoverdose,rememberthatnaloxonehasashorterdurationofactionthan
mostnarcoticdrugs,anddosesthereforeshouldberepeatedatfairlyfrequentintervals.These
patientsrequirelengthy(1224hours)periodsofobservationinhospital.
H.DesignerDrugs
H.DesignerDrugs
Names/Preparations Intoxication Withdrawal
Signsand
Symptoms
Treatment Signsand
Symptoms
Treatment
Fentanylanalogs
Syntheticheroin,
ChinaWhite
Meperidineanalogs
MPPP,MPTP
Similarto
narcotics(above)
Similarto
narcotics(above)
Similarto
narcotics(above)
Similarto
narcotics(above)
Amphetamine
analogs
MDMA,Ecstasy,
Adam,EVE,STP,
PMA,TMA,DOM,
DOB,etc.
Similarto
amphetamines
(above)
Similarto
amphetamines
(above)
Similarto
amphetamines
(above)
Similarto
amphetamines
(above)
PCPAnalogs
PCPy,PCE
SimilartoPCP
(above)
SimilartoPCP
(above)
SimilartoPCP
(above)
SimilartoPCP
(above)
MiscellaneousInformation:MorepopularontheWestCoast,designerdrugscanbebothstronger
andcheaperthantheparentcompound.Qualityisnotcontrolledduringillicitmanufacturing,posing
greatdangertousers.Forexample:MPTP,acontaminantoftheMeperidineanalogMPPP,causes
irreversibleParkinson'sDisease.
Source:
KnightJ.R.,
Substanceuse,abuse,anddependence.In:Levine,M.D.;Carey,W.B.;Crocker,A.C.eds.,
DevelopmentalBehavioralPediatrics,3rded.Philadelphia:W.B.SaundersCo.,inpress.
References:
ChangG.,KostenT.R.
Emergencymanagementofacutedrugintoxication.In:Lowinson,J.H.,Ruiz,P.,Millman,R.B.,
eds.,SubstanceAbuse:AComprehensiveTextbook.Baltimore:Williams&Wilkins,1992.
CenterforSubstanceAbuseTreatment.
GuidelinesfortheTreatmentofAlcoholandOtherDrugAbusingAdolescents.Treatment
ImprovementProtocol(TIP)Series4.DHHSPub.No.932010.Washington,DC:U.S.Government
PrintingOffice,1993.
CenterforSubstanceAbuseTreatment.
DetoxificationforAlcoholandOtherDrugs.TreatmentImprovementProtocol(TIP)Series19.
DHHSPub.No.932010.Washington,DC:U.S.GovernmentPrintingOffice,1995.
Barone,M.A.,ed.
TheHarrietLaneHandbook,14thed.St.Louis:Mosby,1996.
Acknowledgment:
Michael Shannon, M.D., M.P.H. (Toxicology Program) and Brigid Vaughan, M.D. (Department
of Psychiatry) at Children's Hospital, Boston, assisted with preparation of this table.
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Figure12:ContrastsBetweenConfrontationofDenialandMotivational
Interviewing
Figure12
ContrastsBetweenConfrontationofDenialandMotivationalInterviewing
Confrontationofdenialapproach Motivationalinterviewingapproach
Heavyemphasisonacceptanceofselfashavinga
problem;acceptanceofdiagnosisseenasessential
forchange
Deemphasisonlabels;acceptanceof"alcoholism"
orotherlabelsseenasunnecessaryforchangeto
occur
Emphasisonpersonalitypathology,whichreduces
personalchoice,judgment,andcontrol
Emphasisonpersonalchoiceandresponsibilityfor
decidingfuturebehavior
Therapistpresentsperceivedevidenceofproblems
inanattempttoconvincetheclienttoacceptthe
diagnosis
Therapistconductsobjectiveevaluation,but
focusesonelicitingtheclient'sownconcerns
Resistanceisseenas"denial,"atraitcharacteristic
requiringconfrontation
Resistanceisseenasaninterpersonalbehavior
patterninfluencedbythetherapist'sbehavior
Resistanceismetwithargumentationand
correction
Resistanceismetwithreflection
Goalsoftreatmentandstrategiesforchangeare
prescribedfortheclientbythetherapist;clientis
seenas"indenial"andincapableofmakingsound
decisions
Treatmentgoalsandchangestrategiesare
negotiatedbetweenclientandtherapist,basedon
dataandacceptability;client'sinvolvementinand
acceptanceofgoalsareseenasvital
Source:Miller,W.R.,andRollnick,S.MotivationalInterviewing:PreparingPeopletoChangeAddictive
Behavior.NewYork:GuilfordPress,1991.p.53.Reprintedwithpermission.
Figure21:TreatmentStagesandtheProblemSeverityContinuum
Figure22:AdolescentDevelopment:GeneralFeaturesofEarlyandLater
Stages
Figure22
AdolescentDevelopment:GeneralFeaturesofEarlyandLaterStages
EarlyAdolescence LaterAdolescence
CognitiveThinking ConcreteThinking:
Emphasizesimmediate
reactionstobehavior
Maynotbefullyawareof
laterconsequences
MoreAbstractThinking:
Greateruseof
inductive/deductivereasoning
Moreintrospectiveandmore
sensitivetolater
consequences
TaskAreas
1. Family
independence
Beginningrejectionof
parentalguidelines
Ambivalenceaboutwishes
(dependence/independence)
Insistenceonindependence,
privacy
Mayhaveovertrebellionor
sulkywithdrawal;limitsare
oftentested
2. PeersSocial
andSexual
Mostoften"best"friendis
samesex
Boygirlfantasies;littleifany
sexualexperimentation
Dating,intenseinterestin
oppositesex;sexual
experimentationnormal
Risktakingcommon
Needtopleasesignificant
peersofeithersexheightens
3. Schooland
Vacation
Structuredschoolsetting
preferred
Beginningtoidentifyskills,
interests
Startingparttimejob
4. SelfPerception
Identity
Social
Responsibility
Values
Emphasison"AmInormal?"
Tendencytousedenial("It
can'thappentome")
Conformitybehaviorthat
meetspeergroupvalues
Somecontinuetopursue
group/peeracceptance
Someareabletorejectgroup
pressureifnotinselfinterest
ProfessionalApproach
Toretainsanity,staff
should
Liketeenagers
Understand
development
Beflexible
Keepasenseof
humor
Providefirm,directsupport
Conveylimitssimple
concretechoices
Donotalignwithparents,but
dobeanobjectivecaring
adult
Encouragetransference(hero
worship)
Sexualdecisionsdirectly
encouragetowait
Encourageparentalpresence
inclinic,butinterviewteen
alone
Beanobjectivesounding
board(butletadolescents
solveownproblems)
Negotiatechoices
Berolemodel
Don'tgettoomuchhistory
("grandiosestories")
Confrontgentlyabout
consequences,responsibilities
Consider"Whatgivesthem
statusintheeyesofpeers?"
Usepeergroupsessions
Adaptsystemstocrises,walk
ins,impulsiveness,testing
Ensureconfidentiality
Allowteenstoseekcare
independently
Figure23:ClientAssessmentCriteria
Figure23
ClientAssessmentCriteria
Typeof
Treatme
nt
UsePattern Medical
Concerns
Intrapersonal Interpersonal Environmental
Primary
preventi
on
No
histor
yof
use
No
curre
ntuse
Not
applicabl
e
Developmen
tally
appropriate
Effective
copingskills
Moderate
tohigh
emotional/c
ognitive
functioning
Demons
trates
develop
mentall
y
appropr
iate,
prosoci
al
interper
sonal
behavio
r
Maintai
ns
respons
ible
relation
ships
with
significa
nt
others
May
haveno
significa
nt
impact
Anticipat
ory
guidance
and
support
Positi
ve
histor
yof
use
No
curre
ntuse
Not
applicabl
e
Less
effective
copingskills,
but
competent
emotional
and
cognitive
functioning
Demons
trates
develop
mentall
y
appropr
iate
prosoci
al
interper
sonal
behavio
r
Maintai
ns
respons
ible
relation
Oneor
more
environ
mental/c
on
textual
factors
that
increase
personal
vulnerab
ility
(family
history
of
substanc
euse
disorders
ships
with
significa
nt
others
History
of
substan
ceuse
and/or
other
risk
related
behavio
rsthat
increase
the
potenti
alfor
develop
inga
psychoa
ctive
substan
ceuse
disorder
(PSUD)
Ableto
function
ina
nonstru
ctured
setting
)
Brief
office
intervent
ion
Probl
em
resulti
ng
from
use
Low
to
mode
rate
curre
No
anticipat
ed
withdra
wal
Highrisk
peergroup
Stillableto
functionin
nonstructur
edsetting
Maintai
ns
respons
ible
relation
ships
with
significa
nt
others
Oneor
more
environ
mental
risk
factors
ntuse
Outpatie
nt
treatme
nt
Probl
em(s)
resulti
ng
from
useor
low
to
mode
rate
curre
ntuse
Lowto
moderat
euse
without
anticipat
ed
withdra
wal
Less
effective
copingskills
Less
competent
emotional/c
ognitive
functioning
Stillableto
functionina
nonstructur
edsetting
Identifie
d
deficien
ciesin
relation
ships
with
significa
nt
others
and
history
of
substan
ceuse
and/or
other
risk
related
behavio
rsthat
increase
the
potenti
alfor
develop
inga
PSUD
Ableto
function
ina
nonstru
ctured
setting
Environ
mental/
contextu
alfactors
affect
the
individua
lbutdo
not
warrant
removal
from
current
living
situation
Needsto
be
supporte
dby
minimal
treatme
nt
Intensive
outpatie
nt
treatme
nt
Probl
em(s)
resulti
ng
from
use
Mode
rate
to
Subacute
toxicity
Social
support
for
detoxific
ation
Complian
ce
Ineffective
but
functional
copingskills
Less
competent
emotional/c
ognitive
functioning
Identifie
d
deficien
ciesin
relation
ships
with
significa
nt
Environ
mental/
contextu
alfactors
impact
the
individua
lbutdo
not
heavy
recen
tuse
regimen Requires
marginally
structured
setting
others
and
history
of
substan
ceuse
and/or
other
risk
related
behavio
rsthat
increase
the
poten
tialfor
develop
inga
PSUD
Require
s
margina
lly
structur
ed
setting
warrant
removal
from
current
living
situation
Needsto
be
supporte
dby
moderat
e
treatme
nt
Day
treatme
ntpartial
hospitali
zation
Probl
em(s)
resulti
ng
from
use
Mode
rate
to
heavy
recen
tuse
Premorbi
d/sub
acute
toxicity
Complian
twith
detoxific
ation
regimen
Ineffective
but
functional
copingskills
Less
competent
emotional/c
ognitive
functioning
Requires
moderately
structured
setting
Identifie
d
deficien
ciesin
relation
ships
with
significa
nt
others
and
history
of
substan
ceuse
orother
behavio
rsthat
place
Environ
mental/
contextu
alfactors
impact
the
individua
lbutdo
not
warrant
removal
from
current
living
situation
Needsto
be
supporte
dby
individu
alsat
riskfor
develop
ing
PSUD
Require
s
modera
tely
structur
ed
setting
intensive
treatme
nt
Medicall
y
monitor
ed
intensive
inpatient
Probl
em(s)
resulti
ng
from
use
Mode
rate
to
heavy
recen
tuse
Premorbi
d
subacute
toxicity
requiring
24hour
medical
monitori
ng
Other
medical
concerns
that
cannot
be
handled
with
outpatie
nt
treatmen
t
Dysfunction
alcoping
skills
Emotional/c
ognitive/
psychiatric
impairment
requiring
24hour
structured
setting
Dysfunc
tional
relation
ships
and
behavio
rsthat
donot
posean
immedi
ate
threat
toself
and/or
others
butthat
require
24hour
structur
edcare
Environ
mental/
contextu
alfactors
dictate
individua
lmustbe
removed
from
adverse
influence
softhe
current
living
situation
Medicall
y
managed
intensive
inpatient
Probl
em(s)
resulti
ng
from
use
Mode
rate
to
heavy
Morbid,
acute
toxicity
(overdos
e)that
may
require
life
support
All
Dysfunction
alcoping
skills
Emotional/c
ognitive/
psychiatric
impairment
requiring
24hour
structured
Dysfunc
tional
relation
ships
and
behavio
rsthat
may
posean
immedi
Environ
mental/
contextu
alfactors
dictate
individua
lmustbe
removed
from
adverse
recen
tuse
medically
complica
ting
condition
s,
including
those
requiring
lifesup
port/inte
nsive
care
careand
continuous
psychiatric
monitoring
ate
threat
toself
and/or
others
and
that
require
24hour
structur
edcare
and
psychiat
ric
manage
ment
influence
softhe
current
living
situation
Intensive
residenti
al
treatme
nt
Probl
ems
resulti
ng
from
use
No
recen
t
mode
rate
to
heavy
use
No
detoxific
ation
required
Medical
condition
sthat
cannot
be
handled
with
outpatie
nt
medical
manage
ment
and/or
whichdo
not
require
life
support/i
ntensive
treatmen
tservices
Dysfunction
alcoping
skills
Emotional/c
ognitive/
psychiatric
impairment
Requires
longterm
residential
treatment,
including
psychiatric
and
activitiesof
dailyliving
(ADL)
services
Dysfunc
tional
relation
ships
and
behavio
rsthat
donot
posean
immedi
ate
threat
toself
and/or
others
but
which
require
24hour
structur
edcare,
includin
gADL
services
and
possibly
psychiat
ric
services
Environ
mental/
contextu
alfactors
dictate
individua
lmustbe
removed
from
adverse
influence
softhe
current
living
situation
Behavio
r
manage
able
withina
structur
ed
setting
Resident
ial
psychoso
cialcare
Probl
ems
resulti
ng
from
use
No
recen
t
mode
rate
to
heavy
use
Detoxific
ation
services
not
required
No
special
medical
services
required
onsite
Dysfunction
alcoping
skills
Emotional/c
ognitive/
psychiatric
impairment
Requires
supervision
in
structured
setting,ADL,
andother
psychosocial
rehabilitatio
n
Dysfunc
tional
relation
ships
and
behavio
rsthat
donot
posean
immedi
ate
threat
toself
and/or
others
but
which
require
behavio
r
manage
ment
withina
structur
ed
setting
which
provide
s
supervis
ion,
ADL,
and
other
psychos
ocial
rehabilit
Environ
mental/
contextu
alfactors
dictate
individua
lmustbe
removed
from
adverse
influence
sof
current
living
situation
ation
Halfway
house
Probl
ems
resulti
ng
from
use
No
recen
t
mode
rate
to
heavy
use
Detoxific
ation
services
not
required
No
special
medical
services
required
onsite
Adequate
copingskills
Has
moderate
tohighlevel
of
emotional/
cognitive
functioning
butrequires
some
supervision
Ability
to
establis
h
prosoci
al
relation
ships
that
support
recover
y
Ableto
self
regulate
behavio
rwith
minimal
structur
e/super
vision
Environ
mental/
contextu
alfactors
dictate
individua
lmustbe
removed
from
current
living
situation
,or
other
adverse
circumst
ances
Group
home/
group
living
Probl
ems
resulti
ng
from
use
No
recen
t
mode
rate
to
heavy
use
Detoxific
ation
services
not
required
No
special
medical
services
required
onsite
Adequate
copingskills
Has
moderate
tohighlevel
of
emotional/
cognitive
functioning
Abletolive
independent
ly
Ability
to
establis
h
prosoci
al
relation
ships
that
support
recover
y
Self
regulate
s
behavio
r
consiste
ntwith
standar
dsof
respons
Environ
mental/
contextu
alfactors
dictate
individua
lmustbe
removed
from
current
living
situation
,or
other
adverse
circumst
ances
ible
group
living
without
supervis
ion
Figure71:StatusofDrugCourtsintheUnitedStates
Figure71
StatusofDrugCourtsintheUnitedStates
AdolescentPrograms AdultPrograms
Estimatedtotalnumberof
individualswhohaveenrolled
850
a
45,000
b
Averageretentionrates 96percent
c
70percent
c
a
Basedon13activeprograms
b
Basedon99activeprograms
c
Basedonnumberofgraduatesandactiveparticipantsincomparisonwithtotalparticipantsenrolled
Figure72:NumberofDrugCourtProgramsUnderway/Planned
Figure81:DecisionTree
Figure82:SampleConsentForm
Figure82
SampleConsentForm
ConsentfortheReleaseofConfidentialInformation
I,___________________________,authorizeXYZClinictoreceive
(nameofclientorparticipant)
from/discloseto________________________________________
(nameofpersonandorganization)
forthepurposeof_______________________________________
(needfordisclosure)
thefollowinginformation__________________________________
(natureofthedisclosure)
IunderstandthatmyrecordsareprotectedundertheFederalandStateConfidentialityRegulationsand
cannotbedisclosedwithoutmywrittenconsentunlessotherwiseprovidedforintheregulations.Ialso
understandthatImayrevokethisconsentatanytimeexcepttotheextentthatactionhasbeentakenin
relianceonitandthatinanyeventthisconsentexpiresautomaticallyon____________________unless
otherwisespecifiedbelow.
(date,condition,orevent)
Otherexpirationspecifications:
_________________________
Dateexecuted
_________________________
Signatureofclient
________________________
Signatureofparentorguardian,whererequired
Figure83:ConsentForm:CriminalJusticeSystemReferral
Figure83
ConsentForm:CriminalJusticeSystemReferral
ConsentfortheReleaseofConfidentialInformation
I,_____________________________,herebyconsenttocommunication
(nameofdefendant)
between__________________________________________________and
(treatmentprogram)
______________________________________________________________
(court,probation,parole,and/orotherreferringagency)
thefollowinginformation______________________________________
(natureoftheinformation,aslimitedaspossible)
Thepurposeofandneedforthedisclosureistoinformthecriminaljusticeagency(ies)listedaboveof
myattendanceandprogressintreatment.Theextentofinformationtobedisclosedismydiagnosis,
informationaboutmyattendanceorlackofattendanceattreatmentsessions,mycooperationwiththe
treatmentprogramprognosis,and
Iunderstandthatthisconsentwillremainineffectandcannotberevokedbymeuntil:
_____Therehasbeenaformalandeffectiveterminationorrevocationofmyreleasefromconfinement,
probation,orparole,orotherproceedingunderwhichIwasmandatedintotreatmentor
_____
(othertimewhenconsentcanberevokedand/orexpires)
IalsounderstandthatanydisclosuremadeisboundbyPart2ofTitle42oftheCodeofFederal
RegulationsgoverningConfidentialityofAlcoholandDrugAbusePatientRecordsandthatrecipientsof
thisinformationmayrediscloseitonlyinconnectionwiththeirofficialduties.
____________________________
(Date)
____________________________
(Signatureofdefendant/patient)
____________________________
(Signatureofparent,guardian,or
authorizedrepresentativeifrequired)
Figure84:QualifiedServiceOrganizationAgreement
Figure84
QualifiedServiceOrganizationAgreement
XYZServiceCenter("theCenter")andthe_______________________________
(nameoftheprogram)
("theProgram")herebyenterintoaqualifiedserviceorganizationagreement,wherebytheCenter
agreestoprovide
(natureofservicestobeprovided)
Furthermore,theCenter:
(1)acknowledgesthatinreceiving,storing,processing,orotherwisedealingwithanyinformationfrom
theProgramabouttheclientsintheProgram,itisfullyboundbytheprovisionsoftheFederal
regulationsgoverningConfidentialityofAlcoholandDrugAbuseClientRecords,42C.F.R.Part2;and
(2)undertakestoresistinjudicialproceedingsanyefforttoobtainaccesstoinformationpertainingto
clientsotherwisethanasexpresslyprovidedforintheFederalConfidentialityRegulations,42C.F.R.Part
2.
Executedthis____________dayof_____________________,199_____
__________________________
President
XYZServiceCenter
[address]
__________________________
ProgramDirector
[nameofprogram]
[address]