If is often said by recovering alcoholics and drug users that they eventually reached a point at which they could no longer live with or without their substance of choice. When a patient’s system has become habituated to drugs or alcohol being ingested frequently for long periods of time, withdrawal symptoms following cessation can cause serious discomfort and, in some cases, even be life-threatening. For situations such as these, medical professionals often recommend that the patient undergo a drug detox process as the first step in the continuum of services offered to individuals in substance abuse recovery.
Contrary to what the term suggests, medical detox does not involve medically or physically removing drugs and alcohol from the body; rather, it is the process by which the body’s natural ability to purge those substances over time (with the aid of the liver and kidneys) coupled with the substitution of drugs having effects similar to those of the substance they are intended to replace in order to minimize or eliminate the adverse symptoms of withdrawal.
Understanding the Detox Process
According to “Detoxification and Substance Abuse Treatment,” a Treatment Improvement Protocol (TIP) published by the Substance Abuse and Mental Health Services Administration (SAMHSA) in the U.S. National Institutes of Health’s National Library of Medicine (NIH/NLM), medically assisted detox is traditionally undertaken in the following three steps:
- Evaluation: Patient is tested to determine which substances (and at what levels) may be present in his or her bloodstream. He or she is also evaluated for potential dual diagnoses or co-occurring disorders, as well as any preexisting mental/behavioral issues.
- Stabilization: Patient is guided through the detoxification process, most often with the assistance of medications. Counseling on what to expect during treatment and the remainder of one’s recovery process is also generally part of this step.
- Guiding Patient into Treatment: Patient is primed for the actual recovery process. Since detoxification only addresses physical dependency of addiction (and not the psychological aspects of it), it is typically recommended at this stage that the patient commit to enrolling in a drug or alcohol rehabilitation program.
Medical detox programs generally require 3-14 days depending on the severity of the case and the amount of time devoted per day. The physical detox process and accompanying withdrawal symptoms can be over in several days or take many months depending on a number of factors including, but not limited to, the type of substance one is addicted to, the duration and severity of the addiction, family history/genetics, and any medical and/or psychological conditions.
Although medical detox is designed to alleviate symptoms to where they are manageable, certain symptoms are unavoidable and will only subside over time through continued abstinence. Many of these, such as sleeplessness, nervousness/anxiety, and nausea, can be treated with prescription or over-the-counter medications which are beyond the scope of medical detox.
Types of Medical Detox
The following are the most widely recognized types of detox offered by professionally recognized facilities:
- Inpatient Detox: Requires patients to be admitted to a hospital or other facility, where they reside for the duration of treatment, which may range from several days to two weeks. Inpatient is generally recommended for patients having more extreme levels of addiction and/or exhibiting debilitating symptoms (e.g., seizures or delirium tremens) which would require patients to remain under close supervision.
- Outpatient Detox: Requires patients to travel to a hospital or other treatment facility daily (excluding weekends) for treatment sessions. In most cases outpatient detox is the more ideal course of action for patients having milder symptoms.
- Social Model (Non-medical) Detox: Involves extensive monitoring of a patient, typically in an inpatient setting. Rather than being administered medication, the patient undergoes counseling and therapy. Providers of social model detox sometimes also offer additional non-medical services, such as consultation on exercise, nutrition and development of general coping skills.
- Rapid Detox: Involves the use of heavy sedation in conjunction with opioid antagonists such as Naltrexone to “flush” all opiates from the patient’s brain receptors. Numerous recent events have called the efficacy and safety of this method into question; it should also be noted that it tends to be very expensive and is rarely covered by medical insurance. It is recommended that medical professionals be consulted prior to pursuing this course of treatment.
When is Drug and Alcohol Detox Necessary?
Every patient experiences withdrawal differently in terms of the types of symptoms as well as the severity and duration of them. Before determining if detox is the right course of action for a patient, it is always best to consult with a medical professional familiar with that patient’s history and current level of wellness.
As a rule, any individuals for whom detoxing without medical assistance and supervision would potentially be dangerous or perhaps fatal should pursue medical detox as quickly as possible. Additionally, any patients whose withdrawal produces a level of pain or discomfort which greatly diminishes his or her ability to cope with the demands of daily living should consider medical detox as well.
Patients attempting to break dependencies to certain drugs are more likely than not to experience pronounced symptoms warranting medical detox. Examples are heroin, alcohol, prescription pain pills (including opiates as well as benzodiazepines), cocaine and methamphetamine.
Types of Detox Centers
As previously noted, all detox programs are either inpatient or outpatient and are usually selected based on severity of the case and/or the logistical needs of the patient. The American Society of Addiction Medicine (ASAM) delineates types of facilities/levels of care as follows:
- Hospital Inpatient: A general or psychiatric hospital, providing intensive, medically-managed detox and 24-hour supervision. Generally the most optimal venue for patients having elaborate medical needs and/or at risk of complications arising from severe withdrawal.
- Medically-Monitored Inpatient: A standalone detoxification center staffed by medical professionals providing 24-hour monitoring.
- Residential Inpatient: Similar to a Medically-Monitored Inpatient detox, but often residing within a traditional rehab facility providing a greater emphasis on peer support and group therapy than on the administering of medical treatments.
- Intensive Outpatient: Typically in a hospital or physician’s office where patients arrive at scheduled intervals to complete treatment and remain for several hours to be monitored by licensed nurses to ensure that medications are working as planned with minimal or no side effects.
- Outpatient: Generally a physician’s office or standalone facility in which patients are only expected to be present for daily treatment sessions.
Other than inpatient versus outpatient, the most obvious distinction between detox programs and facilities is public versus private. Public, or government-funded, detoxes are often very low-cost or even free, making them a good option for those who are economically disadvantaged and/or have no medical insurance. The downside is that many are underfunded and demand for them is often excessive, resulting in lengthy wait times to enter treatment, minimal personal attention given to each individual case, and very little ability to customize treatment to the needs of the patient.
Privately owned and operated facilities can run the entire gamut from minimalist to luxurious, but most private detoxes are superior to their public counterparts in terms of the quality of the facilities, credentials of the staff, level of care afforded to each individual patient, and flexibility to tailor care plans according to specific requirements. The cost for private detox services is generally significantly higher, but many insurance plans cover the majority of those costs after a small copay.
Benefits of Medical Detox
In addition to providing peace of mind from being in the hands of trained, credentialed professionals, medical detox programs provide the following benefits:
- Launching Pad to Recovery. In addition to providing a much needed medical service, detox programs lay the groundwork for guiding the patient into what will hopefully be a successful treatment program. According to “Understanding Drug Abuse and Addiction: What Science Says” published by the National Institutes on Drug Abuse, “Although detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.”
- Closed, Safe Environment. Whether a patient is fully immersed in an inpatient facility or simply attends several hours a day on an outpatient basis, he or she is able to experience temporary protection from stressful situations and other types of circumstances that trigger cravings and substance use.
- Focus on Sobriety. A controlled atmosphere free of outside distractions enables patients to concentrate on moving closer to recovery and further from their drug of choice.
- Continuity of Care. Patients enrolling in rehabilitation treatment following detox often benefit from the ability to attend the same treatment facility for both phases as they have access to the same resources they are already familiar with and are usually attended to by professionals who are familiar with their case histories, and with whom they have already developed a rapport. Additionally they may have the added benefit of receiving outpatient services alongside individuals with whom they formed friendships during the detox process.
Even if a detox facility does not offer a treatment program, it is typically affiliated with such programs as well as other service providers of interest to patients ready to transition to a treatment program or sober living.
Each patient will be administered a unique combination of detox medications, formulated based on information that is gathered during the initial evaluation pertaining to the patient’s medical and substance abuse histories. In the formulation of the patient’s pharmacological care plan, three considerations are extremely important: (1) any allergies the patient may have, (2) the patient’s dual diagnosis, if any, and (3) potential interaction warnings that may exist between any of the medications the clinician is planning to administer. With these factors taken into account, the clinician will then design a plan according to what has been known to produce the most optimal results in patients with similar profiles.
Alcohol Detox Medications
According to “An Overview of Outpatient and Inpatient Detoxification” published by the National Institute of Alcohol Abuse and Alcoholism (NIAAA), the most commonly used medications for assisting patients during the alcohol detox process are benzodiazepines, or benzos (e.g., diazepam, a.k.a. Valium; lorazepam, a.k.a. Ativan ; and chlordiazepoxide, a.k.a. Librium) which “not only reduce alcohol withdrawal symptoms but also prevent alcohol withdrawal seizures, which occur in an estimated 1 to 4 percent of withdrawal patients.” Certain barbiturates such as Phenobarbital may also be used in cases in which the patient does not respond to benzodiazepines.
Opioid / Heroin Detox Medications
MedlinePlus, a service provided by The U.S. Library of Medicine, states that some of the more commonly utilized medications to treat patients during opioid detox are as follows:
- Methadone and Buprenorphine, a.k.a. Subutrex. Used to alleviate withdrawal symptoms and assist the body in detoxing. Both medications may be used as part of a long-term maintenance regimen.
- Clonidine. Helps to “reduce anxiety, agitation, muscle aches, sweating, runny nose, and cramping.”
- Naltrexone. Aids in preventing relapse.
Benzodiazepine Detox Medications
Some medications used for benzo withdrawal are as follows (note that no medications are specifically FDA-approved for these purposes):
- Buspirone. Utilized to alleviate anxiety, but generally takes 2-3 weeks to take effect.
- SSRI antidepressants (such as Lexapro or Prozac). Sometimes used to counteract anxiety from withdrawals.
- Beta-blockers. Used in the event of tremors.
- Anticonvulsants. Used in the event of seizures.
- Clonidine. Used to stabilize blood pressure.
- Flumazenil. Some effectiveness in addressing general withdrawal symptoms from long-acting benzos, such as clonazepam, a.k.a. Klonopin, or diazepam, a.k.a. Valium.
Stimulants Detox Medications (Cocaine, Methamphetamine, Adderall, etc.)
While there are currently no government–approved medications for stimulant detox, according to “The Search for Medications to Treat Stimulant Dependence” published in NIH/NLM, “recent advances in understanding the processes involved in cocaine addiction have allowed researchers to identify several promising candidates […]. Many of these medications have already shown promise in double-blind, placebo-controlled clinical trials, and virtually all of them are undergoing confirmatory testing. Behavioral and psychosocial treatments, especially VBRT, may augment the efficacy of medication for the treatment of stimulant dependence.” Examples of potentially effective medications cited in the study were Modafinil and Propanolol (cocaine); Bupropion (methamphetamine); and GVG (cocaine and methamphetamine).
What to Expect in Detox Treatments
When patients arrive for the initial evaluation, they will first be expected to complete an intake assessment and interview which will generally include a wide assortment of questions pertaining to medical and psychological history, substance use, and other details relevant to the patient’s case. It is recommended that the patient be as open and honest as possible during this step, so that the most comprehensive detox plan may be customized to best address the patient’s needs. At this time, the patient will also undergo a physical screening to evaluate his or her health and the chemicals present in his or her blood and urine.
Once a plan has been devised with all details from the initial evaluation taken into account, the patient will then meet with the clinician to be administered medications and begin the detox process. In the event that the patient has a dual diagnosis, he or she will also work with a therapist or psychiatrist in order for the treatment plan to be altered as necessary. The ultimate goal is to formulate a course of action that is as painless as possible for the patient yet leaves no stone unturned as far as addressing all relevant concerns and issues.
Once the detox has been completed, the patient will then most likely be meeting with a therapist, clinician or other staff member to devise a plan for the rest of his or her recovery, which may include inpatient treatment, intensive outpatient treatment, less formal outpatient services, aftercare, or any combination of several. The staff member may also recommend participation in 12-step groups, SMART Recovery or any of a host of other non-professional recovery programs.
It is important to remember that the detox process is a very small part of recovery in the greater scheme of things. It only addresses the physical portion of the addiction, and in many cases, post-acute withdrawal symptoms (PAWS) will continue for up to 12 months after detox has been completed. Emotional and psychological recovery from substance abuse can take many years, and successful maintenance of a substance-free lifestyle is, more likely than not, a lifetime affair.
Selecting a Drug and Alcohol Detox Program
Since detox is the critical first step in what is often a very lengthy recovery process, it is important to put as much effort as possible into finding the right one. The following considerations should be taken into account during the selection process:
How reputable is the program?
A good, well-respected detox program will be highlighted by positive press and reviews on the internet and be highly recommended by members of the addiction treatment and medical communities.
How qualified are the staff?
Doctors, counselors, nurses and other support personnel should all have the training, credentials and certification necessary to provide the highest level of service possible; evidence of these qualifications should be readily available on the program’s website.
Does the facility have JCAHO accreditation?
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) periodically inspects all U.S. healthcare facilities, and providers of detox services are expected to demonstrate adherence to rigorous operational and safety standards in order to receive and maintain accreditation.
Is the program covered by insurance? What would be the total out-of-pocket cost of the program (with or without insurance)?
Many insurance plans cover most of the expenditures associated with detox services, but not all programs are recognized by insurance carriers as being legitimate detox providers. In the event that the program is not covered, or that the patient is not insured, it is important to inquire as to the total cost up front and find out if any payment assistance options are available.
Are the accommodations adequate for the needs of the patient?
In an inpatient setting, the facility and staff should be capable of working with any dietary restrictions and special needs the patient may have.
Does the program offer the ability to customize a care plan to the needs of the patient?
Detox is not a “one size fits all” endeavor, and needs can vary drastically from one patient to another. The flexibility of the program to work closely with the patient to tailor a plan according to his or her needs should be evident in the program’s literature or website.
Does the detox program take an evidence-based approach to treatment?
Many experimental treatment methodologies and medications currently exist which are still too new or scarcely utilized to be scientifically proven to have long-term effectiveness. It is always preferable to seek out programs which adhere to evidence-based protocols in their treatment model.
How much emphasis is placed on aftercare?
A good detox center will continually instill in its patients the importance of taking the necessary steps to further their recovery once detox has been completed. Exit assessments, referrals to (and affiliations with) inpatient/outpatient treatment or sober living providers, and counseling sessions to devise long-term recovery plans are all hallmarks of a program with an optimal approach toward aftercare.