Drug or alcohol addiction changes the way the body works, the mind thinks, and the individual functions. The American Society of Addiction Medicine (ASAM) defines addiction as a complex “treatable, chronic medical disease” with pervasive consequences that disrupt many aspects of a person’s life (e.g., family, community, school, work, etc.).1,2 No single treatment is appropriate for everyone.1,3
Effective treatment of a substance use disorder requires several components selected from a variety of approaches developed over more than three decades of scientific research and clinical practice.1,3 Treatment attends to the multiple needs of the individual and not just his or her drug abuse.1,3
Medications are an important element of treatment for many people and are typically combined with counseling and other behavioral therapies.1,3 Medications may be used in many—or all—phases, from detoxification to aftercare. Assessment of treatment modalities—pharmacologic and psychosocial—is continually assessed and reassessed as an individual makes progress along their journey of recovery.
What is Drug Detox?
Drug detox is also known as “medical detoxification” and “medically managed withdrawal.”1,3 The Substance Abuse and Mental Health Services Administration defines detoxification as a “set of interventions aimed at managing acute intoxication and withdrawal” from a substance of abuse.3
ASAM points out that “detoxification alone is rarely sufficient to [maintain recovery and] achieve long-term abstinence,” but it is a critical first step that can help pave the way to effective treatment and rehabilitation.1
Individuals seeking or requiring detox should be matched to appropriate care. Medically assisted withdrawal, where physicians monitor patients and use medications to stabilize or treat an individual, is not always necessary or desirable.
This determination will depend in part on the substance of abuse.3 Individuals addicted to alcohol, sedatives, and/or opioids will experience well-documented and sometimes severe withdrawal syndromes.1,3 Hospitalization or some form of 24-hour medical care is often preferred, required or beneficial.1,3
Medications to Manage Withdrawal
Detoxification is intended to reduce or eliminate any medical consequences of withdrawal, the pain or discomfort of withdrawal and the increased cravings associated with discontinuation.1
Detoxification is not designed to address the psychological, social, and behavioral problems associated with addiction, only the physiologic effects of substance cessation.1
Medications are used during withdrawal for two primary reasons:1
- Suppressing withdrawal through use of a cross-tolerant medication.
- Reducing signs and symptoms of withdrawal.
The remainder of this article reviews some of the medications that have been identified specifically for use during withdrawal syndromes associated with some common substances of abuse.
Keep in mind that medications may also be used during detox to manage co-occurring medical (e.g., hypertension, diabetes, pregnancy, etc.), mental health conditions (e.g., schizophrenia, major depression, etc.), or nutritional deficits.1,3
Medications for Alcohol Withdrawal
Alcohol withdrawal begins approximately 6 to 24 hours since the last drink (or after marked reduction in the quantity of alcohol normally consumed).1 Withdrawal symptoms typically include anxiety, sleep disturbances, vivid dreams, anorexia, nausea, and headache.1,3 Individuals may also experience elevated blood pressure, sweating, hyperactive reflexes, and hyperthermia.1,3 For up to 90% of patients, withdrawal does not progress beyond these mild to moderate symptoms.1
At the most extreme end of the spectrum, patients may experience hallucinations seizures or delirium tremens, a potentially deadly series of symptoms characterized by mental disorientation, tremors, severe anxiety, hallucinations, and drastically increased heart rate, blood pressure, and pulse.1 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.1
Benzodiazepines are the primary choice for treating alcohol withdrawal and reducing the severity of withdrawal as well as the risk of life-threatening seizures.1,3 Diazepam (Valium) and chlordiazepoxide (Librium) are often administrated intravenously or orally.1,3 As longer-acting benzodiazepines, both diazepam and chlordiazepoxide are effective at reducing seizures associated with alcohol withdrawal.1,3
Lorazepam (Ativan) or oxazepam (Serax) are shorter-acting benzodiazepines that also effective in reducing alcohol withdrawal symptoms and may be used when there’s a risk of excess sedation from longer-acting benzodiazepines—this includes the elderly, and those with significant liver disease or patients where prolonged respiratory depression may occur (e.g., chronic obstructive pulmonary disease).1,3
Another class of medications used during alcohol detox is anticonvulsants. Carbamazepine (Tegretol) has been shown to be as effective as benzodiazepines for managing mild to moderate withdrawal.1,4 Unlike benzodiazepines, carbamazepine has no abuse potential, doesn’t inhibit learning and has no abuse potential.1 Research also shows that carbamazepine is associated with less psychiatric distress, a quicker return to work, less rebound drinking, and reduced relapse.1 Carbamazepine’s side effects associated with long-term administration (e.g., nausea, vomiting, dermatitis, etc.) limits the duration it can be used.4
Sodium valproate may be used in a similar fashion to carbamazepine.1
Other medications that show promise for use in alcohol withdrawal and may be better tolerated than benzodiazepines include gabapentin, baclofen, clonidine, atenolol and propranolol.1,3,4
Once individuals complete alcohol detoxification, there are medications that are FDA-approved for treating alcohol use disorder and that have been shown to be effective in combination with behavioral therapies.
Medications for Opioid Withdrawal
Opioids are highly addicting and although their chronic use leads to unpleasant and uncomfortable withdrawal symptoms, they are typically not medically dangerous.3
Using medications for opioid withdrawal is recommended over abrupt cessation, which may lead to strong cravings and can lead to continued use.5
The choice of which medication to use when managing opioid withdrawal is based on several factors, including an assessment that evaluates the extent and intensity of a person’s addiction to opioids, co-occurring mental health disorders, additional drugs of abuse, and the preferred treatment setting (e.g., inpatient or outpatient).1,3,5
Methadone is a long-acting opioid agonist that binds to the same receptors as other opioid drugs; however, it does so more slowly and will not produce euphoria in someone who is dependent on opioids.6 Methadone helps users in withdrawal by alleviating the worst of the symptoms and diminishing cravings.7 Methadone administration must be supervised, as unsupervised administration can lead to misuse and diversion.5 For this reason, it is generally administered in a hospital or treatment center.
Buprenorphine is a partial opioid agonist that binds to opioid receptors but activates them less strongly than a full agonist.6 It has a ceiling effect that limits feelings of euphoria but is still effective in reducing cravings and reducing the severity of withdrawal symptoms.6,7 Buprenorphine doesn’t require supervised administration, and many programs and providers have been granted waivers by the federal government, which gives individuals the freedom to self-administer the medication at home.6
Buprenorphine is sometimes combined with naloxone in a film that’s administered by dissolving it under the tongue. The naloxone has no effect when administered via this route, but should a person dissolve the film in water and try to inject it intravenously, the naloxone—an opioid antagonist—is activated and begins reversing the effects of any opioids in the system, which then precipitates withdrawal symptoms.8
Clonidine is a medication typically used for treating high blood pressure, but it is often used off-label for its ability to reduce the physical sensations of the anxiety and mood swings that are part of withdrawal.5 Clonidine may be used alone, if it isn’t possible to use an opioid agonist like methadone or buprenorphine.7 It may also be used in conjunction with an opioid agonist or other drugs used to manage specific withdrawal symptoms, including:5
- Benzodiazepines for anxiety.
- Loperamide for diarrhea.
- Acetaminophen or non-steroidal anti-inflammatory medications for pain.
- Ondansetron or other agents for nausea.
- Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
- American Society of Addiction Medicine. (2019). Definition of Addiction.
- Substance Abuse and Mental Health Services Administration. (2015). TIP 45: Detoxification and Substance Abuse Treatment.
- Mirijello, A., D’Angelo, C., Ferrulli, A., Vassallo, G., Antonelli, M., Caputo, F., … Addolorato, G. (2015). Identification and Management of Alcohol Withdrawal Syndrome. Drugs, 75(4), 353–365.
- American Society of Addiction Medicine. (2015). The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use.
- National Institute on Drug Abuse. (2018). How do medications to treat opioid use disorder work?
- Substance Abuse and Mental Health Services Administration. (2018). TIP 63: Medications for Opioid Use Disorder.
- National Institute on Drug Abuse. (2018). What is the treatment need versus the diversion risk for opioid use disorder treatment?