Detox Medication — Recovery Binder

Mar 13

Mar 13 Detox Medication

The main goal during detox is to remove drugs or alcohol from the system and stabilize physically.

What Is Drug Detoxification?

Drug addiction is a multilayered psychosocial phenomenon, and for this reason, there should be little surprise to learn that the drug detoxification process can be equally complex. Detoxification, most simply, involves the elimination of drug or alcohol substances from the body. While there is no single crowning definition that encompasses every facet of drug detoxification, the Washington Circle Group (WCG) provides an insightful and workable definition.

WCG is composed of experts in the field of alcohol and drug abuse who share a professional mission to track medical efforts in the field of drug treatment as a means of improving drug prevention, recognition, and treatment on a national scale. According to WCG, detoxification is a medical intervention process that safely helps a substance abuser through the experience of acute withdrawal. The WCG is careful to note that detoxification is a means to an end (recovery), but not an end in itself; after detoxification, recovering drug abusers can best aid the recovery process by entering and staying in a treatment plan.

Identifying the Drug Problem

The drug epidemic in America is multifaceted. While it is a critical first step to look at the face of addiction, the next is to consider whether drug abusers are finding their way into treatment. As long as there is not a 1:1 ratio of drug abusers to persons in treatment, America continues to have a drug problem. In 2009, according to the Substance Abuse and Mental Health Services Administration (SAMHSA, an agency within the U.S. Department of Health and Human Services), 23.5 million people age 12 or older were in need of treatment for an illicit drug or alcohol problem, but only 2.6 million of these people were in treatment at specialty centers.Drug abuse continues to carry a social stigma, and it is often not a transparent activity (family, friends, and colleagues are often in the dark or in denial and may not recognize a person’s drug abuse until it reaches the tipping point). For this reason, one of the most reliable sources of information on drug abuse comes from emergency room intakes. SAMHSA oversees the Drug Abuse Warning Network (DAWN). DAWN is a public health surveillance system that requires SAMHSA to review emergency room visits from participating hospitals that involved recent drug use. The DAWN review encompasses many drugs, such as illicit drugs, over-the-counter drugs like cough suppressants, prescription drugs, alcohol (in some instances), and inhalants with mind-altering effects.
The 2011 DAWN findings included the following:

Drug problems continue to rise. Of all 125 million emergency room visits falling within the purview of DAWN guidelines, more than five million visits were drug-related (including misuse and non-misuse) – a 100-percent increase from 2004.
Age remains a factor in drug use. In the age group of 6-11 years, drug-related emergency room visits amounted to 288 per 100,000 in the population compared to 2,477 visits per 100,000 in the population aged 18 to 20 years.
In the 18-20 age group, drug misuse is often the reason for the drug-related emergency room visit. For instance, in the 18-20 age group, while 2,477 overall had a drug-related visit, over 1,500 presented with drug misuse or abuse.
The trend of drug misuse exists across most of the age groups studied. Of all the age groups studied, there was greater drug misuse than non-misuse in the following age categories: 12-17, 18-20, 21-24, 25-29, 30-34, 35-44, and 45-54.
The incidence of drug misuse is high. Approximately 2.5 million of the emergency room visits that were drug-related involved drug misuse or abuse.

The reality of SAMHSA’s findings is that however effective DAWN may be in collecting data, the actual occurrence of drug misuse and abuse must be even higher. DAWN helps to present a baseline measure of the drug problem in America, and the results are a testament to the need for ongoing drug intervention and treatment, which can be commenced with detoxification services.

The Detoxification Process

Detoxification is widely considered to be the first step in drug treatment. For a drug addict, the psychological burden of detoxification is apparent. Not only may he fear the loss of the drug itself, but also the possibility of undesirable physical, emotional, and mental effects due to the withdrawal. Withdrawal symptoms usually occur when the body becomes habituated to a substance that is consumed over a long enough period of time and then either stopped completely or radically reduced in dosage.

Medical professionals should be consulted prior to beginning any course of detoxification. In many cases, those undergoing detox should be supervised by consulting physicians to ensure health and safety throughout the process.

The following are some general withdrawal symptoms based on some commonly abused drug types:

[8] [9] [10] [11] [12]

Medically Managed Detoxification

Medical professionals trained in detoxification treatment can help treat undesirable effects of withdrawal. Often, the detoxification process includes medications to manage unpleasant withdrawal symptoms and thus make the process safer and more tolerable for the patient. Drug detox management medications can be administered both at inpatient and outpatient facilities.

Medication treatments for withdrawal are linked to the particular type of substance that was abused, the length of time of abuse, and the volume of intake. Some common types of treatments, based on particular drugs, are as follows:

Opioid withdrawal. The U.S. Food and Drug Administration has approved both methadone and buprenorphine (forms include Subutex and Suboxone) for treatment of opioid addiction.[13]
Benzodiazepine withdrawal. Strategies include the patient continuing to take benzodiazepines in gradually decreasing amounts, switching to another benzodiazepine, or phenobarbital substitution.[14]
Stimulant withdrawal. There are no FDA-approved medications acting as antagonists for cocaine addiction treatment. However, inpatient detox programs may utilize benzodiazepines to treat withdrawal from cocaine and methamphetamines. Although benzodiazepines can be addictive, they are prescribed to calm the effects of stimulant withdrawal largely because of the lack of other medication alternatives.[15]

Risks of Quitting Cold Turkey

For many, the method of self-detox, popularly known as “quitting cold turkey,” does not involve medical intervention, and it can lead to fatalities in some cases, such as when a person is a longtime alcohol abuser, benzodiazepine user, or withdrawing from long-term use and/or high amounts of methadone.[16] Users of these drug types therefore will likely require medically supervised detox programs.

Drugs, such as cocaine, amphetamines, and nicotine, do not tend to cause fatality in the withdrawal process, but they can still nonetheless present severe difficulties for the person quitting cold turkey and medical attention should be considered.[17] A serious complication of quitting cold turkey is the relapse factor. The effect of quitting cold turkey is that the body loses its tolerance for the previously abused substances, and if those substances are then reintroduced into the body at the level of prior consumption, there is a high risk of overdose, which can cause death or other serious negative side effects.[18]

Detox Is Necessary but Not Sufficient for Recovery

Recovery from drug addiction is often aptly described metaphorically as a journey on a long road – and the road can be as long as a lifetime. Detoxification is a critical first step, though it will feel like a huge leap for most. The detoxification process addresses the physical dimension of addiction, but still it most often takes months for the brain to return to normal functioning and successfully manage cravings.[19]

Addiction specialists are in near unanimous agreement that detoxification should occur in specialized detoxification facilities.[20] There are several benefits to being in a medically supervised detoxification program, which can effectively:

Stem cravings, as care is supervised and medications may be available to temper any drug abuse impulses
Administer medications to help with any uncomfortable or severe effects of withdrawal
Provide a support system that acts as a soothing mental balm for the emotional and psychological challenges detoxification can present[21]
Offer comforting amenities and non-addiction-forming treatments, including a diet that complements the detox process, nutritional supplements, and pain relievers for body aches and other physical ailments.

Beyond Detox

A 2012 John Hopkins study found that while the relapse rate post-detox is 65 to 80 percent, recovering drug addicts who remained in treatment were 10 times more likely to stay drug-free.[22] The level of time commitment to treatment is also an important factor. Research demonstrates that there is a direct correlation between the length of time in treatment and rate of relapse. In other words, a commitment to treatment has a high rate of return for recovering drug abusers and can be an effective way to combat the perilous odds of relapse.[23]
Treatment must be controlled for quality. The recovery process is not only about being in treatment, but also about being in an effective treatment program. The National Institute on Drug Abuse has provided the following guidelines to assist recovering drug abusers and their loved ones in evaluating the effectiveness of treatment programs:

Treatment plans should not be based a one-size-fits-all approach and must be appropriately tailored to the patient’s needs.
Treatment plans should interact with the patient not only on the physical level of addiction, but also take into account her psychology, social background, and even factors such as age, culture, gender and occupation.
A treatment plan should not be static. It must be periodically reviewed and revised, as necessary, to be most responsive to the patient’s needs.
Many patients have a Dual Diagnosis of drug addiction and mental health disorder(s), and treatment should address all known diagnoses.
Treatment does not have to be voluntary; involuntary treatment does not present a barrier to successful recovery.[24]

Beyond Treatment

Addiction is a chronic disease; in addition to the physical aspects, the psychological and social aspects require healing. Graduation from a drug treatment program does not signal the end of healing. At most, it means that the supervised part of recovery has come to a conclusion, and the program graduate must now apply all the tools and insights culled during treatment. The avoidance of relapse – or stated affirmatively, the continued pursuit of abstinence – is a preeminent concern post-treatment. It is important that the recovering person build a healthy infrastructure for her life. The following measures can be taken to further ensure ongoing and successful recovery:

Engage in healthy social settings that are not reminiscent of the days of using drugs.
Spend time with people who are drug-free and provide a healthy social network.
Remember the structured living environment of treatment and use it as template or guide to create a schedule that supports the healthy use of time.
Actively maintain motivation to avoid falling into stale routines that may lower mood and invite relapse.[25]

In addition, participation in a 12-Step program like Narcotics Anonymous (NA) program can be another healing resource as attending meetings essentially provides therapy at the community level. The faith-based program has long garnered attention as it can bring about a personal transformation that not only can help a drug abuser over to the side of abstinence, but also help him to stay there. The program is based on anonymity, and for this reason, there is little empirical research available about its effectiveness.[26] However, the program continues to grow in popularity; in 1978, there were fewer than 200 registered groups in three countries, but by 1994, groups were holding 19,822 weekly meetings in 70 countries.[27]

In view of the interrelation of many recovery treatment factors for drug abusers, a treatment strategy focused on drug detoxification alone would be myopic and not properly address the possibility of relapse. In the short term, the goal of detoxification is the elimination of drugs from the body system, but even this critical step must comprehend the need for a long-term effective treatment plan. Detoxification, treatment, and aftercare measures can work successively to address each facet of addiction to ensure that abstinence is not only achieved but also maintained.

Shout out and hat tip to dualdiagnosis.org

Medications Used in Detox

For the last several years, between eight and 10 percent of the American adult population aged 12 and older needed specialty

treatment for an alcohol or drug abuse or dependency problem, the National Survey on Drug Use and Health (NSDUH) reports. Many treatment programs begin with a detox program that can be either residential or outpatient, depending on the circumstances. Both types of programs may utilize medications in order to manage withdrawal symptoms that can be uncomfortable and even dangerous if left untreated.

Withdrawal symptoms are usually accompanied by drug cravings. They can be both physical and emotional, and they can include nausea, vomiting, muscle aches, diarrhea, headaches, irregular heart rate, fever, sweats, chills, insomnia, restlessness, anxiety, depression, confusion, hallucinations, shaking and seizures.

Why Medications Are Sometimes Needed

When you abuse drugs or alcohol for a period of time, you may develop a physical and psychological dependency on them, and when you stop taking them, withdrawal symptoms may start. Withdrawal may differ, depending on the type of substance you are dependent on and the length of time you abused drugs or alcohol. For instance, alcohol, opioids and benzodiazepines should never be stopped suddenly without medical supervision, and sometimes intervention as withdrawal can be severe and even life-threatening, especially in the case of alcohol withdrawal. The longer you abuse drugs or alcohol, the more dependent your body likely is on them as well.

Medical detox uses medications to take the edge off and ensure your safety with medical monitoring and supervision in a specialized detox facility. A successful detox program is comprehensive, and it may use both pharmacological methods and psychotherapies in order to help you recover.

Some medications are specifically approved by the U.S. Food and Drug Administration, or FDA, to treat substance abuse and dependency during detox and recovery while others are primarily effective on specific withdrawal symptoms. Currently, there are no medications for the treatment of benzodiazepine or stimulant withdrawal, although different medications may be used during detox to relieve certain side effects and drug cravings.

Medications used during detox may vary and may include:

Opioid detox (heroin and prescription opioid pain relievers):

Methadone
Subutex
Suboxone and Zubsolv
Antidepressants or antiadrenergic agents

Alcohol detox:

Acamprosate
Disulfiram
Naltrexone
Benzodiazepines, including diazepam and chlordiazepoxide
Anticonvulsants such as Depakote or Tegretol
Anti-nausea medications
Antidepressants

Stimulant detox (cocaine, methamphetamine, and prescription ADHD medications):

Modafinil
Antidepressants
Antipsychotics like olanzapine
Benzodiazepines such as diazepam

Sedative or tranquilizer detox (prescription benzodiazepines or benzos):

Substitute long-acting benzodiazepines for short-acting ones like diazepam or chlordiazepoxide
Antiadrenergic agents such as clonidine
Flumazenil

Science continues to evolve, and as new medications become available or evidence shows that others may be effective in additional ways, they may be added to detox protocols. Your medical team will determine which medications are best suited for your personal situation during a detox program.

Methadone, Buprenorphine, Subutex

The Centers for Disease Control and Prevention, or CDC, estimates over two million American adults are addicted to prescription opioid medications. These medications include Vicodin, OxyContin, Percocet, morphine, codeine, and hydrocodone products that are prescribed to relieve pain sensations. When abused, they can cause a euphoric high that can be addicting.

As opioid narcotics are becoming more difficult and expensive to abuse, more people may turn to heroin. Approximately 4.6 million Americans admitted to using heroin at least once in their lifetime, according to a study reported by CNN in 2012, and 467,000 were considered to be dependent on heroin, which is more than double the number of those classified as heroin-dependent in 2002.

Opioids bind to opioid receptor sites in the brain and circumvent the natural reward and pleasure mechanisms. Once your brain expects the drug’s chemical interaction, it may no longer produce the same levels of dopamine, one of the neurotransmitters responsible for pleasure naturally, thus changing the chemical makeup of your brain. When you then take the drugs away, your brain has to struggle to try and restore previous levels of dopamine in order for you to feel happiness, and this can take time.

Withdrawal symptoms can be difficult emotionally, including anxiety and depression. Physical symptoms may mirror the side effects of a bad case of the flu. Withdrawal generally starts within 12 hours of your last dose for an opioid with a shorter half-life and 30 hours for those with longer half-lives. Withdrawal may peak in a few days and can continue for weeks. In order to manage withdrawal, longer-acting opioid agonists, such as methadone or buprenorphine, may be used during detox.

Heroin and most opioid narcotics are short-acting agonists, meaning that they don’t stay in the system for an extended period of time. By switching to a longer-acting opioid like methadone, you will be able to take fewer doses to keep the receptors in the brain engaged. Buprenorphine is a partial opioid agonist and doesn’t fully activate the receptor sites, although is useful in reducing drug cravings and withdrawal symptoms and was approved by the FDA in 2002 to treat opioid dependency specifically. Methadone and buprenorphine can be administered in lower and fewer doses during detox and replace other opioids in the brain without causing the same euphoric or intoxicating effects.

Methadone is dispensed in federally regulated clinics as a tablet, generally taken once per day and classified by the Drug Enforcement Agency (DEA) as a Schedule II controlled substance. Drug scheduling refers to a drug’s potential for abuse and dependency versus its medicinal value, with one having the strictest regulations and five being the least regulated. Methadone is an opioid narcotic itself and therefore does have the potential to be abused and create a dependency.

Buprenorphine, being only a partial opioid agonist, has less potential for abuse due in part to the ceiling effect that occurs when you take more than intended. After levels of buprenorphine reach a certain amount in the bloodstream, the drug no longer produces any euphoria. Buprenorphine is a Schedule III controlled substance and can be prescribed by a doctor either in tablet form or more commonly in a sublingual film strip.

Subutex is a buprenorphine product generally used as an opioid replacement during early detox. Suboxone and Zubsolv also contain naloxone, which is a partial opioid antagonist that blocks opioid from attaching to receptor sites. This means that if you try to take other opioids while on Suboxone or Zubsolv, they will have no effect, and you may start to experience withdrawal symptoms. The naloxone component may serve as an abuse deterrent; therefore, these medications are generally used later on in a detox program.

One of the risk factors for taking buprenorphine medications during detox is the potential for precipitated withdrawal, which is the rapid onset of intense withdrawal side effects. You should wait to begin an a opioid replacement therapy during detox until early withdrawal symptoms have started and the other opioid drugs are mostly out of your bloodstream. Be sure to share all pertinent information regarding the drugs you took, dosage amount, and time of your last dose with the medical professionals assisting you during detox in order to avoid precipitated withdrawal and other potential negative drug interactions.

Read out blog post on Suboxone here.

Benzodiazepines and Anticonvulsants

In 2013, the National Alliance on Alcohol Abuse and Alcoholism (NIAAA) published that 16.6 million American adults aged 18 and older were dependent on alcohol and classified with an alcohol use disorder. Many of the symptoms associated with alcohol withdrawal (headache, nausea, dizziness, drowsiness, muscle aches, trouble concentrating, sweating, loss of appetite, and fatigue) are familiar to the general public. The NIAAA estimates that over 85 percent of American adults have taken at least one drink of an alcoholic beverage in their lifetime, and almost a quarter of the adult population aged 18 and older admits to binge drinking in the month before the 2013 survey.

More problematic is acute withdrawal, which can be more serious and even potentially fatal. When you are dependent on alcohol, medical interventions are often necessary to avoid acute withdrawal, which can begin within eight hours of your last drink and peak in a few days. Acute withdrawal may include symptoms such as vomiting, an imbalance of electrolytes, irregular heart rate, depression, and anxiety.

The NIAAA warns that in five percent of cases alcohol withdrawal can be severe, causing hallucinations, extreme confusion, fever, and seizures, which is called delirium tremens, and can be life-threatening. Untreated alcohol withdrawal can lead to other medical issues as well such as complications with liver disease or the onset of Wernicke-Korsakoff syndrome, a memory disorder caused by an alcohol-induced thiamine deficiency that can lead to dementia and irreversible brain damage.

A partial GABAA receptor agonist and antagonist, flumazenil, has shown promise during benzodiazepine detox when used in conjunction with benzodiazepines to manage withdrawal, as published by the British Journal of Clinical Pharmacology. Benzodiazepines may also be useful during the initial detox from stimulants, such as cocaine or amphetamines. That being said, most of the time, medications are not necessary, and none are specific for the treatment of stimulant dependency. Short-acting benzodiazepines, like diazepam, and lorazepam, can reduce the agitation, paranoia, anxiety and aggression that may accompany stimulant withdrawal.

Fortunately, medications can be utilized during a closely supervised detox program that also includes intravenous fluids as well as heart and blood pressure monitoring to ensure your safety during withdrawal. Benzodiazepines are sedatives and tranquilizer medications that can reduce anxiety, calm seizures, and treat insomnia by reducing gamma amino-butyric acid, or GABA, stimulation in the brain. Diazepam (Valium) and chlordiazepoxide (Librium) are long-acting benzodiazepine medications often administered for this purpose during alcohol detox for a short period of time until a level of physical stabilization is reached.

Anticonvulsant medications such as Depakote or Tegretol may also be used to minimize seizures and involuntary movements. If you have liver damage or disease, benzodiazepines may cause liver failure; your medical detox team can determine if these medications will be beneficial for you.

Other Medications and Supplements

Withdrawal symptoms from most drugs and alcohol typically include emotional side effects, such as anxiety and depression, and, in some cases, suicidal thoughts and behaviors. Mood-stabilizing medications, antidepressants, and antiadrenergic agents can assist in regulating these difficult emotions during detox.

Antidepressants often work by stimulating the production of dopamine or serotonin in the brain, which are commonly affected by substance abuse and dependence. Buspirone acts on the serotonergic system of the body and may be an alternative to methadone tapering during detox, as it has no abuse potential. It also showed a reduction in withdrawal symptoms for heroin addicts in a trial published by the Journal of Clinical Pharmacology. Antiadrenergic agents generally activate serotonin receptors in the brain and function as mood enhancers. Clonidine is one such medication commonly used during detox.

Other drugs may be used for specific withdrawal symptoms and may not be necessarily designed for substance abuse treatment. Anti-nausea medications may be useful during alcohol withdrawal, for instance. Antipsychotic medications like olanzapine can also manage symptoms of psychosis during detox and withdrawal. Modafinil is a narcolepsy drug sometimes used to counteract the crash that can accompany stimulant withdrawal. Herbal supplements, vitamins, and minerals may be recommended by your doctor during detox to help with recovery and healing as well.

The National Alliance on Mental Illnesses (NAMI) reports that 50 percent of drug abusers and 30 percent of alcohol abusers also suffer from mental illness and substance abuse may be a form of self-medication. Therefore, mental illness and substance abuse regularly co-occur, and medications may be required to treat mental illness symptoms during detox. Substance abuse can make mental illness worse and interfere with treatment, just as mental illness symptoms may be complexly intertwined with substance abuse withdrawal side effects. Dual diagnosis treatment ensures that both disorders are treated simultaneously by teams of medical professionals who work together to achieve the best results.

Drug and alcohol cravings may be both psychological and physical, and while they may be partially managed with medications, psychotherapy may produce the best results in alleviating cravings and compulsive drug-seeking behaviors long-term. Acamprosate, disulfiram, and naltrexone are approved by the FDA for the treatment of alcohol dependency, as published by American Family Physician. These drugs serve mainly to deter alcohol abuse as they may increase withdrawal symptoms and block receptor sites in the brain when alcohol is introduced simultaneously. They may be useful later in a detox program to help prevent relapse when used in conjunction with behavioral therapies.

Detox should be a part of a comprehensive treatment program that also includes therapies and counseling sessions in addition to pharmacological methods. A return to drug or alcohol use after a period of detox, or a relapse, can be especially dangerous as it can increase the odds for a life-threatening overdose.

Shout out & hat tip to Rehab International & DualDiagnosis.org