Detoxification – Also called: Detox, Withdrawal Therapy

Detoxification

Also called: Detox, Withdrawal Therapy

Summary

Detoxification is the process of removing a substance and/or its effects from patients who are addicted to the substance. It is not a distinct treatment in itself. Instead, it is the first step in the comprehensive treatment of patients with substance abuse.

The overall goals of detoxification are for the patient to stop taking the substance as quickly and safely as possible and to treat the acute physical effects of withdrawal. Such substances may include alcohol, illegal drugs and prescription medications that are no longer beneficial or are being used for nonprescribed purposes. Withdrawal from many substances can be dangerous or even fatal if not performed under medical supervision.

Detoxification may occur on an inpatient or outpatient basis. The choice between these options depends on various factors, including the substance that was abused, how heavily it was abused and the duration of abuse.

Patients undergo a thorough assessment before detoxification, which includes a complete evaluation of their medical history and a physical examination. During detoxification, patients are withdrawn from their substance of abuse in a consistent manner. Medications are frequently used to treat the symptoms of withdrawal. They may prevent or reverse the symptoms or keep them from becoming worse. Sometimes, a similar substance may be substituted for the substance that was abused.

Withdrawal from different substances produces varying symptoms, and different medications may be used to treat each of them. Sedatives and alcohol are among the most commonly abused substances. They can have very serious withdrawal symptoms, including seizures, delirium and death. Withdrawal from stimulants, such as cocaine, can cause a number of mood disturbances (e.g., depression, anxiety, paranoia) and psychosis (loss of contact with reality). Opioids, or narcotics, may cause withdrawal symptoms such as diarrhea, abdominal cramping, rapid pulse and high blood pressure.

There are several variations of detoxification for patients with dependence on or addiction to opioids. These involve the use of medications, including opiate blockers, to halt the action of narcotics and reduce withdrawal symptoms. Such rapid detoxification occurs in an intensive care unit of a hospital. Depending on the variation, the patient may be unconscious or awake. Rapid detoxification can occur as quickly as four to eight hours or five to 30 minutes. However, it is important to note that rapid detoxification is a controversial treatment with limited support for its use and can result in serious problems including death that are unlikely to occur when other forms of detoxification are employed.

About detoxification

Detoxification (also called “detox”) removes a substance, such as drugs or alcohol, and/or its physical effects from a patient’s body. It is designed to allow the body to quickly cleanse itself of the substance while helping the patient cope with symptoms of withdrawal. Withdrawal occurs when a patient who is physically dependent on a substance stops taking that substance. Such substances may include alcohol, illegal drugs and prescription medications that are no longer beneficial or are being used for nonprescribed purposes.

Detoxification is just the first step in the comprehensive treatment of patients with substance abuse. It addresses only the physical effects of withdrawal and does not treat the psychological, social or behavioral problems of addiction. Lasting recovery is not usually achieved without additional substance abuse treatments to address these other problems. However, detoxification does prepare the patient to undergo further recovery programs.

Detoxification is safest for the patient when it occurs under medical supervision. Withdrawal from many substances, particularly sedatives and alcohol, can be dangerous or even fatal if not performed under the supervision of a medical professional.Properly supervised detoxification typically involves medications to ease withdrawal symptoms and make detoxification much easier on the patient. The duration and intensity of detoxification depends on several factors, the most important being the type of substance being abused and the duration of abuse. Most detoxification programs require several days to a few weeks.

Conditions treated with detoxification

Detoxification is used to treat withdrawal caused by addiction or dependency and help patients rid their bodies of substances, including:

  • Sedatives. Also called depressants, these are among the most commonly abused substances. They include medications that have been used as sleep aids or to assist in relaxation (e.g., barbiturates, benzodiazepines). Minor signs and symptoms of withdrawal from these substances include restlessness, anxiety, insomnia and sweating. More serious signs and symptoms of withdrawal include hallucinations, tremors (shakiness), seizures, high blood pressure, rapid pulse and delirium. Untreated withdrawal from these drugs can be life threatening.
  • Alcohol. This is another type of depressant. Withdrawal from alcohol abuse can cause a range of symptoms. Mild to moderate withdrawal symptoms can usually be treated outside a facility and without medications. However, supportive care, monitoring and daily follow-ups are necessary. Patients at risk of serious withdrawal symptoms (e.g., seizures, delirium) and those with certain other medical conditions generally require more extensive inpatient treatment. The most dangerous symptom of alcohol withdrawal is delirium tremens (DTs), which is characterized by tremors (shakiness) and delirium. Untreated withdrawal from alcohol can be life threatening.
  • Stimulants. Cocaine is among the most frequently abused stimulant drugs. The typical signs and symptoms of stimulant withdrawal include depression, fatigue, anxiety and intense cravings for the substance. Other signs and symptoms of withdrawal include suicidal thoughts or attempts, paranoia and acute psychosis (impaired perception of reality). No medications have been proven effective for cocaine detoxification. However, many show promise and are frequently used to treat withdrawal symptoms.
  • Opioids. These drugs are also called narcotics. They include legal prescription pain killers (e.g., morphine, oxycodone, codeine) and illicit varieties (e.g., heroin). Minor signs and symptoms of opioid withdrawal include a runny nose, sweating, yawning, anxiety and a craving for the substance. Patients with only mild to moderate withdrawal symptoms may be candidates for outpatient detoxification, although medications are still required. Patients with severe withdrawal symptoms generally require more extensive detoxification. Though patients who go through untreated withdrawal from opioids can be in marked discomfort, it is rarely life threatening. Severe signs and symptoms of opioid withdrawal include:
    • Vomiting
    • Diarrhea
    • Shakiness (tremors)
    • Insomnia
    • Depression
    • Dilated pupils
    • Abdominal cramps
    • Bone and muscle pain
    • Rapid pulse
    • Rapid breathing
    • High blood pressure

Types and differences of detoxification

Detoxification may occur on an inpatient or outpatient basis. The choice of inpatient or outpatient treatment depends on various factors, including:

  • The substance that was abused
  • How heavily it was abused and for how long
  • Any other history of substance abuse
  • The patient’s age and social issues
  • Any other medical or psychiatric conditions the patient may have

Many treatment centers have their own detoxification facilities. Others arrange for patients to attend detoxification programs at nearby hospitals, clinics or other sites. Outpatient facilities include mental health centers, addiction clinics and private clinics. This form of treatment is less expensive and does not disrupt the patient’s life as much as inpatient detoxification.

Inpatient facilities include hospitals and residential treatment centers. With inpatient detoxification, the patient can be closely monitored and may be exposed to the substance of abuse or other medications under strict medical supervision. Inpatient detoxification may be more rapid than outpatient detoxification.

Before, during and after detoxification

Patients receive a formal assessment before they begin detoxification. This includes a thorough evaluation of their medical history, particularly of any other history of substance abuse and any other current medical or psychological conditions. A physical examination is also performed before detoxification.

During detoxification, patients are withdrawn from their substance of abuse in a consistent manner. This treats the acute physical effects of withdrawal and removes the toxins from the patient’s body. Detoxification generally involves medical monitoring and support, and medications. Other therapies, such as mental health counseling, may take place at the same time as detoxification.

Depending on the substance abused and the individual patient’s reactions to the substance and medications used during detoxification, patients may remain under medical supervision for an extended period even during outpatient treatment. Patients undergoing outpatient care may also be required to return to the facility frequently for monitoring. The degree of this frequency (e.g., several times a week, weekly, biweekly) varies among patients.

Medications are frequently used to treat the symptoms of withdrawal. They may prevent or reverse the symptoms or keep them from getting worse. Because withdrawal from different substances produces a variety of symptoms, different medications may be used to treat them. In some cases, the substance that was abused may be given in increasingly smaller doses.

As an alternative, a similar substance may be substituted for the substance that was abused. Some facilities prefer symptom-triggered dosing. Here, medications are given in response to individual symptoms instead of at regular intervals.

Benzodiazepines are tranquilizers that are frequently used in inpatient and outpatient detoxification from alcohol because they can prevent the seizures and delirium of alcohol withdrawal.

Long-acting benzodiazepines are often used for alcohol detoxification. These tend to require very few doses, often just one every six hours during the first 24 hours. The dosages of short-acting benzodiazepines must be tapered over four to eight days. These medications are processed and removed from the body rapidly, so they may be safer in some patients. Short-acting benzodiazepines are generally recommended for patients with significant liver disease, cognitive impairment, unstable medical health, and those over the age of 65 years.

Opioid withdrawal is often treated with a mild synthetic opioid that is substituted for the narcotic of abuse. Methadone is among the most common of these. Its dosage is typically slowly reduced until it is no longer taken. This process generally takes about 21 days but may be more rapid depending upon how much opioid medication the person was using. Buprenorphine is another synthetic opioid that may be used instead of methadone. It is newer than methadone and may be combined with naloxone, an opioid antagonist. An opioid antagonist is a medication that blocks the effects of narcotics.

Other medications that may be used during detoxification include:

  • Antidepressants. These medications may be used during stimulant (e.g., cocaine) detoxification. They help to treat withdrawal symptoms such as anxiety and depression.

  • Amantadine. This medication is commonly used in the treatment of Parkinson’s disease. It is also useful in detoxification for people addicted to or dependent on stimulants. It helps to treat severe withdrawal symptoms and cravings.

  • Bromocriptine. This medication affects the neurotransmitter dopamine, which is involved in emotion and mood. Bromocriptine is sometimes used to treat stimulant detoxification. It helps ease cravings and reduce mood disturbances.

  • Beta blockers. These medications are frequently used to reduce the workload of the heart and blood pressure. They may be useful in stimulant and sedative detoxification. They can help to treat severe withdrawal symptoms, including anxiety, rapid pulse, sweating and cravings.

  • Clonidine. This medication is generally used to treat high blood pressure. It may also ease the symptoms of withdrawal from opioids and depressants such as alcohol. When used for narcotic detoxification, it may be combined with naltrexone, an opioid antagonist.

  • Carbamazepine. An anticonvulsant medication. It may be used in alcohol and other sedative detoxification to treat the seizures or delirium that may occur during withdrawal.

The duration of detoxification depends upon the substance abused, how heavily it was abused and the length of abuse. Some patients may undergo detoxification more quickly than others. Different techniques may also alter the duration of the treatment. However, detoxification generally takes several days to a few weeks. Following detoxification, the patient moves on to rehabilitation, although patients are often able to enter rehabilitation while still undergoing detoxification. Detoxification should be performed in conjunction with recovery programs and self-help meetings. The continued treatment for substance abuse picks up where detoxification leaves off. Any lingering effects of withdrawal that may occur after the physical dependence has been treated in detoxification, such as anxiety or cravings, will be dealt with in this further treatment.

Potential benefits and risks of detoxification

Detoxification allows patients who are dependent or addicted to a substance to overcome the symptoms of withdrawal so that they can stop their reliance on the substance. With proper medical supervision, the symptoms of withdrawal can be prevented or treated. However, many withdrawal symptoms can still occur. These can often be quite painful or distressing. Still, these reduced withdrawal symptoms are typically a better option than the dangerous consequences of withdrawal without medical supervision. Even after the substance has been removed from the patient’s body and physical dependence has been treated, lingering effects of withdrawal (e.g., anxiety, cravings) may continue. These are dealt with in further substance abuse treatment.

In many cases, the medications used in the treatment of substance withdrawal have their own potential for abuse. Many of these medications, including benzodiazepines, may lead to addiction and dependency and the need for detoxification. However, when taken as directed under medical supervision, this risk is low.

Alternatives and variations of detoxification

There are several variations of detoxification for patients with dependence on or addiction to opioids, or narcotics. These alternatives to conventional opioid detoxification include:

  • Rapid detoxification. Patients are placed under general anesthesia. While unconscious, they are given intervenous injections of medications. Opiate blockers (e.g., naltrexone, naloxone), which halt the action of narcotics, are the most important of these. Medications that reduce withdrawal symptoms (e.g., muscle relaxants, anti-nausea medications) are also given. Rapid detoxification should be performed in an intensive care unit of a hospital. Because they are not conscious, patients generally feel none of the withdrawal symptoms.

    Using this method, detoxification occurs within four to eight hours. Patients are discharged once they have recovered from the anesthesia and physicians have made sure that they are not experiencing any complications. This usually occurs within 48 hours. Rapid detoxification is not for everyone, though. It is expensive and poses all the risks associated with general anesthesia, including death. It is best for patients who experience severe withdrawal symptoms or have failed conventional detoxification repeatedly.
  • Stepped rapid detoxification. Here, patients are alert and in direct communication with the medical staff. About every hour, they are given small doses of naloxone injected just under the skin and naltrexone in pill form. They are also given medications for withdrawal symptoms as needed. Buprenorphine, a substitute medication, is often used for these. It is usually placed in tablet form under the tongue. This form of detoxification is slower than standard rapid detoxification but much faster than conventional detoxification. The pacing of the medications can be controlled in response to withdrawal symptoms. Because of this, there is less need for medications to manage these symptoms.
  • Ultra rapid detoxification. Like rapid detoxification, patients in ultra rapid detoxification are placed under general anesthesia. They are given intravenous injections of naltrexone in elevated doses. Using this method, complete detoxification occurs within five to 30 minutes. However, ultra rapid detoxification can be painful despite the anesthesia. It is also expensive and poses all the risks associated with general anesthesia.

The general anesthesia required for rapid detoxification should only be administered by an anesthesiologist or a nurse anesthestist under the direct supervision of an anesthesiologist.

It is important to note that all forms of rapid detoxification are controversial and there is limited support for their use. There is no research that shows they are more likely to result in successful detoxification than more conservative modalities that do not pose the same risk of serious side effects.  Furthermore, rapid detoxification does not eliminate the need for the patient to enter a rehabilitation program to manage the psychosocial aspects of addiction

Questions for your doctor about detoxification

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following detoxification-related questions:

  1. Why do I need to undergo detoxification?
  2. Am I at risk for serious withdrawal symptoms?
  3. Do you suggest inpatient or outpatient detoxification for me?
  4. What medications, if any, will I be given during detoxification?
  5. How long is my detoxification likely to last?
  6. Will I still experience withdrawal symptoms during detoxification? If so, how strong will they be?
  7. How will my cravings be handled?
  8. Won’t I get hooked on the medications used to help me get through withdrawal?
  9. What continued treatment should I seek following my detoxification?
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