Understanding Detox


For every person seeking professional help with their recovery, exactly how their course of treatment will progress—including the potentially distressing period of detoxification and accompanying withdrawal to develop in the first few days to weeks after quitting drugs or alcohol—may vary considerably from one individual to the next.

Some of the factors that may impact the detox experience for any given individual may include:1,2

  • The specific substance(s) having been consistently used.
  • The average amount of substance(s) being used prior to the cessation of use.
  • The duration of consistent drug or alcohol use prior to quitting.
  • The magnitude/degree of physiological dependence and neuroadaptation to the substance use in question.
  • The presence of any significant co-occurring mental or physical health issues.
  • Previous history of difficult or complicated withdrawal episodes.

In early recovery, managing the unpleasant and, in some cases, dangerous symptoms of acute drug or alcohol withdrawal will be the primary focus of the detox treatment team. Patient monitoring, support, and medical/pharmaceutical interventions will be administered as needed to stabilize those in withdrawal to keep them as comfortable and safe as possible in this earliest period of recovery.

In addition to providing a safe, supportive environment for withdrawal management, another important function of professional detoxification programs lies in their efforts to prepare a patient for entry into a substance abuse treatment program. In other words, as the withdrawal management period is winding down, the detox treatment team helps each individual  prepare to transition into a program of ongoing substance rehabilitation to continue the recovery efforts started during detox.2

Of note, when it comes to substance withdrawal:

  • Alcohol use can lead to significant physical dependence and a potentially-severe associated withdrawal syndrome. The symptoms of acute alcohol withdrawal may range from troublesome to life-threatening, and many who attempt to quit drinking seek the help of professional alcohol detox to manage symptoms and minimize the risk of withdrawal complications. Despite the known risks and the potential for preventive interventions (e.g., seizure prophylaxis), alcohol withdrawal remains underrecognized and undertreated.2 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) reports that an estimated 88,000 Americans die each year of alcohol-related issues—including withdrawal-related causes.3
  • In addition to alcohol, opioids—whether prescription painkillers like hydrocodone (e.g., Vicodin) and oxycodone (e.g., OxyContin, Percocet) or illicit (heroin)—are associated with a significant and often markedly unpleasant withdrawal syndrome. However, it is not just opiates that can lead to significant withdrawal symptoms when the drugs are suddenly stopped. Stimulant drugs, too, such as cocaine, amphetamine (e.g., Adderall) and methamphetamine are sometimes associated with significant withdrawal symptoms—often predominantly psychological in nature (e.g., dysphoria, intense cravings).2 In the case of methamphetamine, such withdrawal effects, in addition to some potential changes to brain structure and function with chronic use, can make quitting particularly difficult.4,5
  • Prescription central nervous system depressant drugs (e.g., sedatives, hypnotics, and anxiolytics) may also lead to the development of dependence and withdrawal. Drugs in this group include sleep medications (e.g., Ambien, Lunesta) and anti-anxiety medications (e.g., Ativan, Xanax).
  • The legal status of several substances has nothing to do with a corresponding potential for dependence and withdrawal. Certain prescription medications (e.g., stimulants, sedatives, and painkillers), alcohol, and even marijuana have known liability for misuse, dependence, and associated withdrawal phenomena; in many instances, those who have developed an addiction to these drugs may benefit from professional detox and treatment.

How Does Medical Detox Help?

Medical detox programs aim to help people more safely and comfortably navigate the initial phase of treatment for drug and/or alcohol addiction. There are different settings and levels of intensity for professional detoxification services—for example, some are inpatient and some are outpatient. Each may offer a different range of services from supervision and supportive measures to more acute care settings equipped for relatively intensive monitoring and pharmaceutical interventions that lead into longer-term therapeutic treatment.

The level of care that will be most appropriate will be a factor of the type of substance dependence, the magnitude of such dependence, individual circumstances and certain other personal details, such as any previous addiction treatment efforts, a prior history of withdrawal complications, any significant co-occurring mental or physical health issues, and goals for recovery.

The Substance Abuse and Mental Health Services Administration (SAMHSA) indicates, in one of its Treatment Improvement Protocols, that there are three essential components of detoxification—evaluation, stabilization, and fostering patient entry into treatment. Though program specifics are likely to vary, medical detox may work towards these three elements through a combination of the following:2

  • Monitoring and treatment: An initial medical evaluation may be conducted to assess withdrawal risks and to identify any further medical needs. Not everyone will be in need of acute medical care upon entering a medical detox program, but those who are will have access to treatment interventions needed to stabilize them in withdrawal and minimize the risk of complications, such as seizures and agitation.
  • Counseling and peer support: Patients may be kept better engaged with their detoxification program through the efforts of clinicians in providing hope, reassurance, education about the withdrawal process, instruction for how to deal with cravings, and relapse prevention skills training. Counselors may also start working early on to enhance motivation for patients to continue on with comprehensive treatment at the completion of the withdrawal management period. Attendance of 12-Step or other mutual support meetings during the detoxification stage may also reinforce the need for continued substance abuse treatment as detox winds down.
  • Referral or start of treatment: Detox services do not encompass the sum total of treatment services necessary to overcome addiction. Ideally, when detox is complete, a period of more comprehensive substance abuse treatment therapeutic treatment should begin. Some detox programs are integrated into a comprehensive rehabilitation program while others will culminate with referrals and arrangements to transfer to additional therapeutic services.

FAQ

Do all drugs cause withdrawal symptoms?

Many substances known to lead to the development of dependence are also be associated with a discontinuation or acute withdrawal syndrome. The phenomenon of withdrawal is one of the diagnostic criteria for many types of substance use disorders, including alcohol use disorder, opioid use disorder, stimulant use disorder, and sedative, hypnotic, and anxiolytic use disorder. Not all substances are clearly associated with a withdrawal syndrome, however, including some hallucinogens, dissociatives like phencyclidine (PCP), and many inhalant chemicals.6 Even without a distinct withdrawal syndrome, the use of these drugs is still associated with the compulsive, problematic patterns of use common to addiction, though treatment for such use might not require an intensive detoxification period.

Can medication help?

Just as all aspects of addiction treatment are influenced by the specific needs of the individual, so too should the choice regarding use of treatment medications. Not all drugs of abuse have a corresponding pharmacotherapeutic option that will improve the detox experience.

However, for withdrawal management in cases of alcohol and opioid dependence, there are FDA approved medications commonly used to stabilize a person during detox and, later, potentially used as maintenance medication for longer-term treatment.

For example, several benzodiazepine agents have the medical management of alcohol withdrawal among their approved uses. Such benzos include chlordiazepoxide (Librium) and diazepam (Valium).In For both stabilization and maintenance therapy for opioid use disorders, the opioid agonists methadone and buprenorphine are commonly used to help people manage withdrawal symptoms and reduce relapse risks.2,6 Coupled with behavioral therapeutic interventions, these options serve as the pillars of medication-assisted treatment, and have helped many in recovery from heroin and other opioid use disorders.2

Despite such pharmacologic support, when applicable, none of these options should viewed as a magic pill in terms of eliminating all withdrawal symptoms and removing all of the challenges of detox. There are, however, a number of medications that may be helpful in easing the severity of withdrawal symptoms, minimizing unnecessary suffering, and better empowering the individual to more quickly begin a longer-period of therapeutic treatment or rehabilitation.

Can you die from withdrawal symptoms?

In some cases, yes. The physical effects associated with certain types of significant dependence and associated withdrawal—for instance, alcohol and benzodiazepines—may be so severe as to be life-threatening. The complications of such withdrawal syndromes include marked agitation and uninterrupted seizures (status epilepticus). These and certain other withdrawal risks may be compounded in instances of co-occurring medical disorders (e.g., seizure disorders, cardiovascular disease, etc.) or in a setting of polysubstance abuse (e.g., concurrent opioid and alcohol use).2

For individuals at risk of severe or complicated withdrawal, diligent patient monitoring and pharmaceutical intervention as part of a medical detox program can help keep them as safe and comfortable as possible throughout the period of acute withdrawal.

What is ‘cold turkey’ detox?

Going cold turkey is a colloquial phrase used to describe the process of abrupt cessation of use of all drugs and alcohol with no medical assistance of any kind. In several situations—including those involving significant alcohol dependence or opioid dependence—such unmonitored, unassisted attempts to stop drinking and/or quit drugs are ill-advised, as the associated withdrawal syndrome may be particularly unpleasant, presenting unnecessary challenges to early recovery, and, in some cases, dangerous.2

Is there medical supervision during professional detox?

It depends on the level of care offered at a particular program, which is likely to be a reflection of the withdrawal management needs of the individual in question. In some instances, medical monitoring and intensive medical management may not be necessary. Such a setting may be referred to as a social detoxification program, in which peer/social support is emphasized over the availability of medical intervention.2 Even in such a program, participants could potentially be escalated to a more intensive level of care, should their particular withdrawal progress warrant additional attention or medical attention.

How long do withdrawal symptoms last?

The length of time that withdrawal symptoms last in detox will vary based on a number of different factors. In general, they can be expected to begin within several hours after the last drink or last use of the drug in question, peaking over the course of the next few days, and largely resolving within days to weeks. In some instances—sometimes referred to as protracted withdrawal or post-acute withdrawal—vestiges of certain troublesome withdrawal symptoms may persist for several months (and, in other cases, years) beyond the period of more-commonly-seen symptom resolution.8

Factors that have an impact on the time of onset for and total duration of withdrawal symptoms include:

  • Primary substance of dependence: Different substances have different pharmacologic properties and correspondingly-diverse physiological effects. For example, someone who struggles with an opiate addiction may have different withdrawal symptoms than someone who is detoxing from marijuana. How long symptoms will last is often heavily dependent upon the drug of addiction.
  • Average dose and chronicity of use: The amount of drug being regularly used as well as the length of time that such use has been taking place are also important. Those with a relatively short history of moderate use may be at less risk of experiencing a severe withdrawal than someone with years of high dose use driving significant physiological dependence, for example.
  • Polysubstance use: When other drugs and/or alcohol are thrown into the mix, the nature of the corresponding multi-substance withdrawal syndrome may be additionally severe and/or complicated.2 For example, if the primary drug of choice is heroin, but the person often used the drug with speed, then withdrawal symptoms associated with both substances may be an issue.
  • Physiology: Differences in individual metabolic rates, the efficiency of specific enzymatic processes, as well as their general state of liver and kidney health, etc. may somewhat influence the onset and duration of withdrawal symptoms.

What happens after detox?

Detox is just the first part of a comprehensive treatment program for addiction.9 After the withdrawal period has been successfully managed, patients will ideally transition into a longer period of substance rehabilitation, where they may better learn how to make the behavioral changes necessary to remaining drug-free in recovery. Substance abuse treatment efforts often emphasize a combination of behavioral therapeutic interventions, allowing the person in recovery to explore underlying assumptions and perceptions that may be contributing to the impulse to use drugs and alcohol, and make adjustments where necessary. Additionally, more holistic or complementary therapeutic options augment evidence-based behavioral therapies and provide help with stress management and overall wellness.

What is rapid detox or ultra-rapid detox?

It is understandable that people who have committed to recovery may want to progress through the sometimes-unpleasant period of detox and withdrawal management as quickly as possible. There has been some historical investigation into the utility of rapid or ultra-rapid detox protocols as a means to achieve a swift progression through opioid withdrawal. However, such approaches are not in widespread use and, in the case of ultra-rapid, general anesthesia-assisted methods, may be associated with potentially lethal adverse events.8

Can dual diagnosis issues be managed in detox/treatment?

Addiction and mental health conditions frequently coincide. It has been estimated that as many as 6 out of 10 people with substance use issues have at least one other mental health condition at play.10 Fortunately, the research evidence supports the role of an integrated treatment approach in simultaneously managing co-occurring disorders or dual-diagnosis conditions. As with other detox/treatment methods, this may entail a combination of both medication and behavioral therapies.10

References

  1. Herron, J.H, & Brennan, T.K. (2015). The ASAM Essentials of Addiction Medicine, Second Edition. Philadelphia: Wolters Kluwer.
  2. Substance Abuse and Mental Health Services Administration. (2015). TIP 45: Detoxification and Substance Abuse Treatment.
  3. National Institute on Alcohol Abuse and Alcoholism. (2019). Alcohol Facts and Statistics.
  4. National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition)—Preface.
  5. National Institute on Drug Abuse. (2014). Methamphetamine Alters Brain Structures, Impairs Mental Flexibility.
  6. Diagnostic and statistical manual of mental disorders: DSM-5(5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
  7. Hamilton, RJ. (2019). Tarascon Pocket Pharmacopoeia, 2019 Deluxe Lab-Coat Edition. Jones & Bartlett Learning.
  8. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
  9. National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition)—Principles of Effective Treatment.
  10. National Institute on Drug Abuse. (2007). Addiction and Co-Occurring Mental Disorders.


About The Contributor

Scot Thomas, M.D.
Scot Thomas, M.D.

Senior Medical Editor, American Addiction Centers

Dr. Thomas received his medical degree from the University of California, San Diego School of Medicine. During his medical studies, Dr. Thomas saw firsthand the multitude of lives impacted by struggles with substance abuse and addiction, motivating... Read More


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