Understanding Medical Detox
Admitting that a problem exists is generally considered the hardest part of addiction recovery, but drug detox often stops substance users from attempting recovery at all. Clients have to be clean and thinking clearly before drug rehabilitation starts. Medical detox is the detoxification and stabilization phase of recovery.
Medical detox takes place under medical supervision. A combination of medications and other interventions minimise emotional and physical withdrawal symptoms. This helps clients function normally and avoid relapse. Medication-assisted treatment is available for people addicted to almost any substance, but it is primarily associated with alcohol, stimulants, and opioids or opiates. (2)
Doctors at a medical detox centre administer tapering medications to reduce the chance of an adverse reaction after an abrupt end to substance abuse. Clients are weaned off a drug slowly instead of abruptly, which increases safety. Prescription medications are given to help clients sleep, reduce anxiety and control cravings. (6)
Medical detox treatment is accessible through several avenues. Substances users planning to self-pay do not need a referral to attend a private rehabilitation or medical detox.
Enrolment in NHS-funded programmes requires a referral from a GP or other health care professional. Clients are also eligible for specialised substance abuse programmes through a referral from community-based services or court order. (4)
The Importance of Medical Detox
The UK has the highest rates of substance abuse and addiction in Europe. Approximately one out of every three adults in England and Wales has used recreational drugs at least once. The Office for National Statistics reported 2,928 drug-related deaths in England during 2008. Heroin is the most common opiate-related death. (4)
There were approximately 1.1 million hospital admissions in 2017-2018 with a primary or secondary diagnosis related to alcohol. (11) Over 9% of adults in the United Kingdom used an illicit drug at least once during 2017, and 17,031 hospital admissions were a result of drug poisoning or misuse. (12) The prevalence of addiction and drug- or alcohol-related deaths in the UK requires dedicated effort to help people and save lives. Medical detox is an essential tool to help substance users get into treatment and recover successfully.
Medical detox offers an opportunity to address underlying physical, mental and emotional medical issues. Many people with substance abuse disorders also have mental health disorders such as major depression, schizophrenia, bipolar disorder or borderline personality disorder. (8)
Doctors and other health care professionals in a medical setting thoroughly evaluate clients. Many drug rehabilitation programs require clients to attend medical detox before beginning treatment. (3)
Why Is Medication Used for Detox?
Medications are used during detox to ease withdrawal symptoms and stabilise mood or overall mental status. Vivitrol and Revia contain forms of naltrexone that block opioid receptors in the brain. Clients taking naltrexone do not feel any effects from using other opiates. (10)
Medications such as buprenorphine and methadone prevent most symptoms of opiate withdrawal. A person’s mood and emotions are often erratic during withdrawals, so medications to relieve anxiety and depression are very helpful. (7)
Medications are almost always necessary for safe benzodiazepine detox. Common symptoms of benzodiazepine withdrawal include sleep disturbance, irritability, anxiety, panic attacks, tremors, sweating, difficulty in concentration, vomiting, nausea, weight loss, heart palpitations, headache and muscle pains. The more dangerous and severe symptoms are seizures and psychotic reactions. (9)
The risk of life-threatening complications of benzodiazepine withdrawal is highest in the first four days after the last dose. Withdrawal symptoms tend to be more severe with long-term use, but there is such extreme variation between individuals that everyone going through detox from benzodiazepines should be under medical supervision. (5)
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Medication Replacement Programmes for Medical Detox
Methadone and buprenorphine are the most common replacement drugs for opioids. Dose induction is the process of gradually administering higher doses to find the optimal dose for preventing withdrawal. Methadone induction is done slowly to lower the risk of overdose. The risk of death from methadone toxicity is highest during the first two weeks of treatment. (5)
Methadone’s half-life is between 13 to 50 hours, and it varies significantly between individuals. Methadone’s half-life can even vary between doses for the same person during the first weeks of treatment. (5)
Suboxone and Subutex are brand names for a medication combining buprenorphine and naltrexone. Buprenorphine is a partial agonist. It does not stimulate opioid receptors in the brain to the same extent as a full agonist.
Buprenorphine induction is faster than methadone induction. The limited activity at opioid receptor sites limits respiratory depression, so there is very little risk of overdose. (5)
Benzodiazepine addiction is sometimes treated with substitution. A benzodiazepine with a short half-life, such as alprazolam, is more likely to be abused than a benzodiazepine with a longer half-life. A benzodiazepine with a long half-life, usually diazepam, is administered and tapered slowly to help clients detox from their drug of choice. (9)
Medications Used for Medical Detox
Benzodiazepines
Benzodiazepines are a large class of synthetic medications. Although many medications are classified as benzodiazepines, almost all of them depress the central nervous system and cause drowsiness or sleepiness. The mechanism of action of benzodiazepines is not completely understood, but they work by enhancing effects of gamma-aminobutyric acid, or GABA, and other neurotransmitters in the brain.(9)
Methadone
Methadone is a synthetic, long-acting opioid that binds with more receptors in the brain than any other known opiate or opioid. Methadone affects the release of neurotransmitters such as acetylcholine, norepinephrine, substance P, and dopamine. Methadone is used for treatment of opioid dependence, and it is often used to treat severe, chronic pain. (10)
Buprenorphine
Buprenorphine is a partial opioid agonist. It activates opioid receptors in the brain, but it doesn’t fully activate them. The opioid effects have a ceiling that is much weaker than a full agonist like heroin. The ceiling on opioid effects lowers the potential for abuse, and it does not carry the same risk of overdose. (5)
Suboxone
Suboxone is a combination of buprenorphine and naloxone. It is used to treat opiate addiction, and it is not pain medication. Naloxone blocks the euphoric and analgesic effects of other opioids. Buprenorphine also blocks effects of other opioids, so taking Suboxone while another opioid is still present in the body induces precipitated withdrawal. (5)
Antidepressants
Antidepressants are a staple of medical detox. People struggling with addiction frequently have co-occurring mental health disorders. Severe depression and suicidal thoughts are very common in individuals detoxing from amphetamines. People often experience withdrawal when they stop taking antidepressants too, so it is very important to take these medications exactly as prescribed. (10)
Non-opioid agonists
Anti-inflammatory drugs (NSAIDs) and steroids are non-opioid pain medications. Aspirin, ibuprofen and naproxen are common NSAIDs. These medications are not addictive, but they do have side effects. NSAIDs cause irritation of the GI tract, and they can aggravate kidney or liver damage. (14) Steroids reduce inflammation and treat auto-immune disorders by suppressing the immune system, but they also increase susceptibility to illness and infection. (15)
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Opioid agonists
All opioids are agonists. This means they stimulate the opioid receptors in the brain. Binding to the opioid receptors produces the euphoric effect, commonly known as a high, and the analgesic effects provided by pain medications such as morphine, hydrocodone and fentanyl. Opioid agonists also act on the central nervous system and slow respiration. (10)
Opioid antagonists
Opioid antagonists bind to opiate receptor sites in the brain without stimulating them. Naltrexone and naloxone are opioid antagonists strong enough to temporarily displace opioid agonists at receptor sites. Opioid antagonists reverse overdose symptoms, but they also cause precipitated withdrawal because agonists are immediately pushed out of receptors. (10)
Acamprosate
Acamprosate, or Campral, regulates the neurotransmitters and chemicals in the brain related to alcohol dependence. Acamprosate is added to medication regimes at the end of the detox process, and it is only used to manage alcoholism. This medication is a mood stabiliser and curbs cravings, but it does not relieve physical withdrawal symptoms. (10)
Naltrexone
Naltrexone is not a narcotic, but it blocks the effects of narcotics. Naltrexone causes precipitated withdrawal, so it cannot be given until the person is completely clean and no longer physically dependent on opiates. It is meant to help substance users stay clean, and Naltrexone may block the effects of alcohol as well. (10)
Disulfiram
Disulfiram, also known as Antabuse, is used to treat chronic alcoholism. A person taking disulfiram experiences a negative reaction within 10 minutes of consuming alcohol.
The reaction causes hot flashes, sweating, headache, nausea, vomiting, chest pain, weakness, blurred vision, confusion, breathing difficulty, anxiety or seizures. Disulfiram is controversial because the severe reaction can be life-threatening. (10)
Diazepam
Diazepam, or Valium, is a benzodiazepine used to relieve muscle spasms and treat anxiety and seizures. Although diazepam is an addictive substance, it is often used during alcohol detox. Diazepam relieves anxiety, delirium tremens and emotional distress during alcohol withdrawals. It may also prevent or treat seizures in combination with other medications. (10)
Chlordiazepoxide
Chlordiazepoxide, or Librium, is a benzodiazepine used to treat acute alcohol withdrawal and anxiety. It produces a calming effect by enhancing a neurotransmitter, GABA, in the brain and central nervous system. Chlordiazepoxide is taken orally and should be taken exactly as prescribed. It is important not to stop taking this drug abruptly.
Anticonvulsants
Anticonvulsants are used to manage alcohol dependence during acute withdrawals and the period of protracted abstinence syndrome when the risk of relapse is high. Benzodiazepines are used to manage alcohol withdrawals as well, but anticonvulsants are a good choice if the client is addicted to multiple substances. (10)
Depakote
Depakote is used to treat epilepsy and bipolar disorder. It acts on various neurotransmitters to prevent seizures and act as a mood stabiliser. Depakote is used in medical detox during benzodiazepine and alcohol withdrawal because withdrawal from both substances can provoke seizures. It also helps clients with co-occurring mood disorders. (10)
Tegretol
Tegretol is an anticonvulsant used to treat trigeminal neuralgia, bipolar disorder, post-traumatic stress disorder and several other mood disorders. Tegretol is used off-label in drug rehabilitation to relieve anxiety and restless leg syndrome associated with withdrawal from alcohol, benzodiazepines and opiates. It can also be used in combination with other drugs to control seizures. (10)
Anti-nausea medications
Anti-nausea medications relieve symptoms of withdrawal. Many people experience nausea and vomiting during withdrawal regardless of their drug of choice. Prescription strength anti-nausea medications such as Zofran, promethazine or Reglan treat symptoms as they occur. Over-the-counter medications including Pepto-Bismol and antacids are often used as well. (10)
Duration of a Medical Detox
Physical and emotional withdrawal symptoms of opioid, barbiturate and benzodiazepine dependence usually start within 8-12 hours of the last dose. The time required to complete detox varies according to gender, age and individual metabolism. It is also affected by the type, amount and half-life of the client’s drug of choice.
The National Treatment Agency (NTA) states that detoxification takes, on average, 2.4 weeks for opiates, 1.8 weeks for alcohol, 2.1 weeks for stimulants and 3.4 weeks for benzodiazepines. (3)
A drug’s half-life is the time it takes for the concentration of the drug in blood plasma to be reduced by 50%. In more direct terms, the half-life is the time required for concentrations of the drug in the body to reach half of the initial dose.
Opiate detox can be completed in as little as one week or last as long as six weeks. Opiates with a long half-life, such as methadone and suboxone, have a longer detox period than short-acting opiates like heroin and fentanyl. (5)
Detox from alcohol lasts from three to 14 days, depending on the individual, duration of alcohol use and amount of alcohol used per day. (1) Benzodiazepines usually have the longest detox duration of any drug.
The longer detox length of benzodiazepines is a result of the extensive half-life of many types of benzodiazepines and the severity of changes in brain chemistry brought about by long-term benzodiazepine use. (9)
Medical Detox Success Rate
Only 35% of substance users remained abstinent five years after receiving community-based services. (3) The National Treatment Agency for Substance Misuse found better results in 2012. According to its 2012 study, people treated for addiction at the highest-performing inpatient treatment facilities across the UK had five-year abstinence success rates between 60% and 80%.
Unfortunately, facilities with very poor performance managed only a 20% success rate (2), but the remarkably high success rates achieved by top performers is convincing evidence of the treatment model’s effectiveness.
A 2006 DORIS study followed 1,033 drug users from Scotland to evaluate abstinence success rates. Substance users had a 25% five-year success rate after residential treatment. Only 6% of substance users remained abstinent for five years after community-based services.
Overall, 30% of substance users remained abstinent for 90 days following residential drug rehabilitation as opposed to only 3% of those who did not attend residential treatment. (2)
Dual Diagnosis in Medical Detox
Many people with a substance use disorder also have a mental health or behavioural disorder. Addiction with another mental or behavioural diagnosis is known as dual diagnosis. Of people who began addiction treatment in 2018, 41% had a dual diagnosis. (2) Effective treatment and successful recovery for individuals with a dual diagnosis requires an integrated treatment plan.
Substance users frequently begin using as an attempt to self-medicate and relieve symptoms of a mental health disorder. Common dual diagnosis disorders include attention-deficit hyperactive disorder (ADHD), bipolar disorder, borderline personality disorder, depression, generalised anxiety disorder (GAD), obsessive compulsive disorder, post-traumatic stress disorder, schizophrenia and eating disorders.
Opioid users have the highest prevalence of dual diagnosis, followed by alcohol users. (1) Substance abuse can aggravate or mimic symptoms of mental illness. Marijuana use can provoke psychosis in people with certain mental illnesses, especially schizophrenia.
Genetics may predispose some individuals to develop a mental disorder or addiction. Environmental factors including chronic stress, constant anxiety or traumatic events can trigger addiction or symptoms of mental illness. (8)
A psychosocial evaluation determines behavioural and social factors that present a challenge to addiction recovery. The initial assessment evaluates physical and neurological functioning, medical history, mental status, risk of violence or suicide, and previous experiences with detox or addiction treatment. (8)
Therapy and Medical Detox Combined
Effective treatment and successful recovery for individuals with a dual diagnosis requires an integrated treatment plan. Clients learn to recognise maladaptive behaviours and replace them with healthy coping skills.
Substance users may need months, or even years, of mental health therapy to recover from the loneliness, anxiety and chronic stress of addiction. Evidence-based behavioural therapy helps clients recognise the cause of high-risk behaviours. Cognitive-Behavioural Therapy (CBT) is frequently employed to treat addiction and other mental health disorders such as borderline personality disorder. It gives clients the tools to recognise cravings and identify the underlying reasons. Clients who engage in CBT develop personalised strategies to manage stress and high-risk situations in their daily lives. (13)
Contingency Management (CM) is a type of behavioural therapy used to treat addiction to stimulants, opioids and alcohol. CM uses a system of tangible rewards for positive behaviour and abstinence. (6) Dialectical behavioural therapy (DBT) is helpful for clients experiencing thoughts of suicide or self-harm. DBT teaches acceptance and control of unpleasant thoughts and emotions through relaxation techniques. Yoga, controlled breathing and muscle relaxation let clients tolerate harmful thoughts and eventually decrease the frequency and intensity of self-harming behaviours. (13)
Residential Treatment Centres vs. Outpatient Services
Clients using outpatient detoxification treatment normally travel to a hospital or other treatment facility daily. Most outpatient treatment supplies enough medication for clients to skip visiting the centre on weekends.
Treatment sessions can last for hours in the morning or evening, depending on the programme’s schedule. Outpatient detox is often completed faster than inpatient detox, but some outpatient programs use a slower tapering process.
Outpatient treatment lets individuals continue working, attending school and engaging in other activities of daily life. Substance users concerned about losing their jobs or leaving their families may be more likely to start treatment with outpatient detox. Outpatient services are usually less expensive than inpatient treatment as well.
Inpatient detoxification takes place in a hospital or drug rehabilitation facility, and clients stay in the facility at all times. The length of an inpatient stay varies between programmes. Some facilities use a standard 30-day stay, while others tailor the length of a client’s stay based on individual factors.
Both inpatient and outpatient detox involve an initial assessment and medications to ease withdrawal symptoms and use some form of drug testing to monitor client progress.
Advantages of Inpatient Medical Detox
One of the many advantages of inpatient medical detox is a vastly lower risk of relapse. Outpatient detox leaves clients with easy access to drugs or alcohol during the detox process, while inpatient treatment surrounds clients with a supportive environment and limits access to substances outside the facility. (2)
More extensive medical care is available through inpatient detox. A person experiencing seizures or other serious side effects receives care quickly during inpatient detox because medical professionals monitor clients continuously.
Anticonvulsants and strong benzodiazepines are safer for inpatient use under medical supervision. Many doctors won’t prescribe such powerful medications on an outpatient basis. (3)
Clients have access to treatment for co-occurring mental disorders and underlying physical health issues during inpatient detox. Inpatient medical detox also lets medical staff monitoring clients when they begin taking antidepressants. Reactions to antidepressants vary greatly between individuals, so finding the most effective medication often involves some degree of trial and error.
Suicidal ideation is a possible side effect of antidepressant use. Medical staff at an inpatient facility provide help immediately to keep clients safe if a negative reaction occurs. (2)
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Questions to Ask Treatment Centres
Preparing a list of questions to ask treatment centres is helpful for choosing a programme and feeling comfortable with the decision. Ask if rehabilitation and detox programs at the centre are covered by the NHS.
If services are not on the NHS, find out specific costs for treatment. Ask which symptoms of withdrawal are treated with medication and if the centre uses substitution drugs or tapering for opioid addiction. (3)
Find out how far the treatment centre is from home, friends and family. Clients and families both feel better after learning rules for phone calls, mail and visitation. Ask for a complete version of behavioural policies such as smoking or non-smoking, smoking frequency and if coffee or other beverages containing caffeine are allowed.
Discuss the desired outcome of treatment and ask if each client conforms to an overall treatment programme or if programmes are customised for individuals. Some people prefer a faith-based atmosphere and interventions, while others prefer to avoid religious aspects. (4)
Substance users with specific dietary preferences should ask if the centre can accommodate them. It is also beneficial to know if the centre has a nutritional component. Properly balanced nutrition is healthy and supportive overall, and it can be of great benefit for clients who may have neglected their health during addiction. (3)
Sources:
- (1) https://www.gov.uk/government/publications/substance-misuse-treatment-for-adults-statistics-2017-to-2018/alcohol-and-drug-treatment-for-adults-statistics-summary-2017-to-2018
- (2) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/752993/AdultSubstanceMisuseStatisticsfromNDTMS2017-18.pdf
- (3) http://www.executive-rehab-guide.co.uk/private-alcohol-and-drug-rehab/success-rates
- (4) http://tvscn.nhs.uk/wp-content/uploads/2017/12/Gordon-Morse-Addiction-and-Substance-misuse-pathways-1.pdf
- (5) https://webarchive.nationalarchives.gov.uk/20170807160700/http://www.nta.nhs.uk/uploads/clinical_guidelines_2007.pdf
- (6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657308/
- (7) https://www.drugabuse.gov/
- (8) https://www.dualdiagnosis.org/
- (9) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657308/
- (10) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4014033/
- (11) https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-alcohol/2018/part-1
- (12) https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-drug-misuse/november-2018-update
- (13) https://www.drugrehab.com/treatment/types-of-therapy/
- (14) https://lagunatreatment.com/non-opioid-agonists-abuse/
- (15) https://medlineplus.gov/steroids.html
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