What Medications Are Used During Drug Detox?
Breaking the physical hold of a drug addiction is the first step of recovery, but this is often its own challenge. Drugs change the way the body works, and it takes a lot of time and help to undo the damage. Using specific medications during drug detox will make the process bearable, and ensure the best prospects for long-term rehabilitation.
What Is Drug Detox?
Drug detox is also known as medical detoxification, a process where the person goes through withdrawal from their addiction, but under careful medical supervision. Medical detoxes are designed to prevent users from relapsing on their substance use when the stress of withdrawal becomes too much. Seeing the process through to the end is a critical component of a successful recovery.
Many people experience addiction as both a physical and a mental health problem. The chemical molecules in drugs and alcohol change how the brain operates (so much so that the brain even experiences structural changes), and this affects how the body functions. However, the sensations of consumption and reaction are initially supremely pleasurable, far beyond any natural experience. As the user craves more stimulation, physical and psychological dependence on the drug increases.
At some point during the addiction, some individuals try to quit their habit. They may have run out of money to keep their intake up, or they may have decided that their drug use has gone on too long. Whatever the reason, there is often the temptation to go “cold turkey,” to just stop taking any more substances. This is successful for a small percentage of people, usually those who have the right combination of factors: genetics, health, or a relatively mild dependence on their drugs. For most other people, however, going cold turkey is a painful, distressing experience of physical and mental stress, so much so that they are desperate for more drugs or in grave danger of developing other problems, even life-threatening ones.
This stress happens because drugs disbalance key chemical systems in the brain, often targeting the centers of the brain that deal with the perception of pleasure, reward, anticipation, and memory, among many others. If a drug problem continues for any length of time, the person comes to make very strong positive associations with the drug, and the brain itself becomes dependent on the chemical manipulations to simply survive. Take the drug away without warning, and the balance does not simply go back to its initial position. It swings wildly, desperately trying to find stability. Internally, this looks like hyperactivity, the brain sending frenzied signals to rediscover its optimum working points. Externally, people feel anything from paralyzing depression to the flu, from insomnia to an unfathomable desire for more drugs to make the pain go away.
Medications to Treat Withdrawal Symptoms
The symptoms of withdrawal depend to a large degree on the nature of the drug use, and the individual’s own physiology (overall health, age, lifestyle, the presence of other drugs, and other factors). Some symptoms are unique to the substances being detoxed while many others overlap. In general, individuals will usually experience digestive distress (nausea, vomiting, and diarrhea), flulike symptoms, periods of depression and anxiety, and an intense craving to go back on their drugs. If properly monitored and addressed, the symptoms should last for around a week, but this also depends on multiple factors. In cases of chronic drug abuse, some people deal with lingering symptoms for months after their last consumption.
In order to avoid or mitigate the worst of the complications that can arise during detox, doctors can administer specific medications to help the person weather the hardest parts of the process. The medications are administered on the basis of the individual’s medical history, current health, history of drug use, the presence of other drugs, and a number of other factors. This list cannot be accurately determined if the person attempts to detox at home or without medical supervision, and it is one of the many reasons why medical detox is the safest and most effective way to start kicking a habit. With this kind of an evaluation, a doctor can create a customized detox program to control the unpleasant effects of withdrawal and ensure the best chance at long-term recovery.
When it comes to using medications during drug detox, the idea is that they will help a user taper off the problem substance as comfortably as possible. Specific treatments address specific drugs, in order to minimize the risk of adverse effects and maximize the ease with which the various stages of withdrawal are experienced. With time, the person can fully wean off the drug while the most common side effects of withdrawal are addressed by medical staff. This sets the stage for a resumption of a normal diet, rest, psychological therapy, and aftercare support, none of which are possible if the person is still enduring the full brunt of withdrawal.
For example, in alcohol detox, there is a legitimate danger that the symptoms of withdrawal can reach such a severity that the individual’s life can be at risk. About 25% of patients dependent on alcohol who do not receive adequate treatment can experience grand mal seizures in the first five days of the withdrawal process. At the most extreme end of the spectrum, patients experience delirium tremens, a series of symptoms characterized by mental disorientation, tremors, severe anxiety, hallucinations, and drastically increased heart rate, blood pressure, and pulse. Delirium tremens is the most life-threatening of the complications that can arise from alcohol withdrawal, and without medical treatment, the seizures it induces can be permanently disabling or fatal.
However, there are many medications that have been proven to be effective in helping alcohol-addicted patients get through withdrawal without any of these complications arising. The drugs used in alcohol detox have been shown to significantly reduce the severity of symptoms and the likelihood of emergency complications.
Benzodiazepines make up a class of drugs that are considered the primary choice for treating alcohol detox. Benzodiazepines are usually administered at high doses early in treatment before being gradually reduced as time passes. In this way, patients have a reduced chance of suffering from the dangerous effects of withdrawal. Benzodiazepines come in a number of different forms, so choosing the right one depends on the treatment setting, the physiological health of the patient, and the doctor’s own preference. Examples of benzodiazepines for alcohol detoxification can include:
- Diazepam (brand name Valium) and chlordiazepoxide (Librium) can be administered intravenously or by oral consumption. Of all the benzodiazepines available to treat withdrawal, diazepam and chlordiazepoxide are among the most popular because they have long half-lives (the period of time it takes for half of the dose to be eliminated from the bloodstream); this, in turn, controls withdrawal symptoms between doses.
- Lorazepam (Ativan) is normally prescribed for anxiety, but it has been approved for certain off-label use as an anticonvulsant; this makes it useful to reduce the risk of seizures in patients who might experience delirium tremens as part of their detox. The American Family Physician journal notes that Ativan has an “excellent record of efficacy” for treating alcohol withdrawal.
- Oxazepam (Serax) has a slower absorption rate and a shorter half-life than diazepam, so it is at a disadvantage when compared to other benzodiazepines for drug detox. For this reason, it is sometimes used in the treatment of mild to moderate alcohol withdrawal, but rarely beyond that. However, oxazepam has been associated with successful outcomes for people with alcohol use disorder who have experienced severe liver failure.
- Clorazepate (Tranxene) is designed to treat anxiety and seizures. Like other benzodiazepines, it has proven effective in reducing electrical activity in the brain, dulling the extremes of alcohol withdrawal, and helping patients move toward the end of the process with minimal amounts of distress.
Anticonvulsants and Other Medications for Alcohol Detox
Another class of medications used during alcohol detox is anticonvulsants, which have found popularity in Europe because they have less of a potential for abuse than sedatives like benzodiazepines, but they have not been fully researched in the U.S. for their use in withdrawal. Examples include carbamazepine (trade name Tegretol) for mild to moderate withdrawal symptoms. Some research has suggested that carbamazepine is better at deterring early relapse than benzodiazepines. Gabapentin (Neurontin) might be equally as good as benzodiazepines for reducing withdrawal symptoms.
Other medications that can be used during alcohol detox include clonidine (brand name Catapres). Clonidine is an alpha-adrenergic agonist, which can bring down symptoms of high blood pressure and rapid heartbeat during withdrawal. Doctors might not prescribe clonidine if the patient is at risk for seizures, however, since clonidine would be ineffective for this purpose.
To protect against seizures, there is phenobarbital—the only type of barbiturate used during alcohol detox. Phenobarbital resembles benzodiazepines in how it moderates withdrawal symptoms, but its administration has to be closely monitored because it is very addictive and has a narrow therapeutic index (where minute differences in dose or blood concentration can lead to a dependence based on dose and blood concentration as well as therapeutic failures or adverse reactions to it).
Beta blockers are like clonidine in that they do not do much to help with more life-threatening alcohol withdrawal symptoms, but they are useful in treating the cardiac symptoms of detox, such as hypertension and rapid heartbeat.
Medication-Assisted Treatment for Opioid Withdrawal
For opioid detox, the method of using drugs to help with the detox process is known as medication-assisted treatment (MAT). STAT News explains that the way opioids work in the brain requires a specific pharmacological approach for treatment and long-term rehabilitation. When a person takes an opioid (anything from heroin or fentanyl to OxyContin or codeine), the molecules in the opioid cross the blood-brain barrier and bind to specific opioid receptors in the brain and central nervous system. This causes a chain reaction of brain activity and neurotransmitter release that causes the infamous euphoric high followed by a complete lack of perception of pain. The impression is so devastatingly powerful that most users experience an imperceptible physical and psychological dependence on the opioid. In time, the dependence becomes very perceptible. If there are other factors at play, the dependence becomes a complete addiction to the opioid.
Where medication-assisted treatment enters the picture is when the person is ready to break the physical need for opioids. With MAT, doctors administer opioids that activate the same brain and central nervous system receptors, but these opioids are slow-acting. They are absorbed into the blood over a longer period of time, which keeps the withdrawal symptoms at bay and cuts off the mental association between taking an opioid and feeling the immediate high. This is because the opioids that are abused (whether illegal or prescription) tend to be full opioid agonists, meaning that they activate receptor cells to the fullest possible extent, pushing dopamine production to the highest degree and having the greatest analgesic effect and, with it, the strongest withdrawal symptoms.
The opioids given during medication-assisted treatment are partial opioid agonists. They bind to the same receptors, but not to the same degree as full agonists. As a result, patients feel some of the narcotic comfort, but not to the extent that it creates a psychological dependence.
Another kind of opiate that can be administered during MAT is an opioid antagonist, which is a nonopioid drug that that binds to the same receptors, but instead of activating those receptors, it blocks them. This way, if a person relapses on opioids, the molecules in those opioids cannot make it past the antagonist sitting on the receptor. However, if a person stops taking their antagonists and then relapses on a full agonist, it can be fatal. Tolerance for a drug decreases after sobriety, so the threshold for dangerous use is much lower.
Examples of partial opioid agonists for medication-assisted treatment include:
- Methadone is a long-acting opioid, and it is has traditionally been the first line of treatment for people looking to detox off opioid abuse. Methadone will help users in withdrawal by alleviating the worst of the symptoms and diminishing cravings. Because it is a long-acting opioid, users will not feel the powerful euphoria that comes from a short-acting opioid. However, methadone is still a full opioid agonist, so there is a risk that a patient with an opioid dependence could develop a psychological need for the methadone therapy.
- Buprenorphine is another partial opioid agonist that limits the effects of opioid withdrawal and puts a cap on the pleasure and sedation that come with full agonists. It is sometimes administered with naloxone, an opioid antagonist; the brand name of this combination is known as Suboxone. As an antagonist, naloxone immediately cuts off access to opioid receptors, which can throw patients into withdrawal upon administration. To reduce the risks of sudden withdrawal, naloxone is bundled with buprenorphine.
- Clonidine was originally formulated for treating high blood pressure. This effect makes it a useful treatment for drug detox because of how it can reduce the physical sensations of the anxiety and mood swings that are part of withdrawal. Clonidine can also help boost attention and suppress impulsivity, so patients might experience a decline in cravings for opioids.
There is concern about giving opioid-dependent people more opioids to wean them off their addictions, but medication-assisted treatment is considered the “gold standard” of drug detox, especially at a time when opioid abuse rates are at an all-time high. Giving specific medications to people to help them through withdrawal is the first step on the long road of recovery.