What is detox?
Detoxification, or detox, generally refers to the process of removing toxins from the body. In the case of substance use, detox specifically refers to the period of time that the body is allowed to process or metabolize any drugs and alcohol in the system and, in doing so, clears their toxic influence. Formal detox programs can provide a number of interventions to assist with:
- Safely and comfortably clearing the body completely of the unwanted substance.
- Managing symptoms of acute withdrawal.
- Encouraging ongoing substance use disorder treatment for the detoxing individual.
Detox is separated into two types:
- Medically assisted (or medically supervised) detox – This type of treatment is done under the care of medical and mental health professionals. The observation is helpful to increase safety and comfort levels for people undergoing the painful symptoms and potential medical complications that may result from ending substance use. At times, medications can be administered to ease the process and reduce the strong cravings for the substance that typically are experienced at this point.
- Clinically managed (“social”) detox – This style is a short-term, non-medical strategy for someone wanting to end substance use. Some social detox settings will only provide a room for detox to take place while others will provide more hands-on treatment approaches including peer encouragement and professional support throughout the detox duration.
The best option will depend on the substance being abused, the current level of physical dependence and the desire/need of the individual to use or not use medically assisted techniques.
3 Stages of Detox
According to Substance Abuse and Mental Health Services Administration, detox is comprised of three stages:
Evaluation. This step will assess:
- The presence of alcohol and drugs through urine, breath, or blood testing.
- The person’s current mental health state.
- Any existing medical issues.
- The most appropriate strategy.
- Stabilization. This will consume the majority of treatment. It will begin with acclimating the person to the detox process as well as providing medical and/or psychological services to treat symptoms, if required.
- Build willingness for further treatment. Detox alone does not constitute thorough addiction treatment. As withdrawal symptoms resolve throughout the detoxification period, staff will typically begin promoting further treatment to increase the chances of sustained recovery following detox.
Who should go to detox?
Detox is a recommended initial step of treatment for a wide range of addicted individuals. Some form of detox is appropriate for anyone who has developed a substance dependency.
Dependency means that the body has adapted to persistently elevated levels of a substance in such as way that the individual begins to feel like they must take the drug in order to simply feel as if they are functioning normally. When the drug is withdrawn, dependent individuals will often experience a host of mental and physical health symptoms that are uncomfortable and potentially dangerous.
People that have had negative experiences with previous withdrawal, significant mental or physical health issues, and limited support at home will likely benefit from medically supervised detox.
Medically-assisted detox is most appropriate for people with substance dependencies involving:
- Hypnotic/sedative drugs like barbiturates and benzodiazepines.
- Opioids like heroin, morphine, and prescription pain medication.
Ceasing use of these substances can lead to adverse effects that range from significantly uncomfortable to fatal, depending on the type of drug being abused, the chronicity of such abuse, and the individual’s medical history.
For other drugs associated with a less dangerous or difficult withdrawal syndrome, detox might not require close medical management. For these substances, it might be adequately conducted in the social detox setting or foregone completely as the individual enrolls in some other form of substance abuse treatment.
How long does detox take?
There is no set timeframe for detox to be completed. For some, the process will only take hours or days. For others, it may take weeks to completely clear the body of the drug. Factors that dictate the length of detox include:
- The drug of abuse.
- The rate, dose, and duration of use.
- The presence of any poly-substance abuse.
- The detox setting.
- The goals of the patient.
- Previous detox attempts.
- The individual’s health condition.
The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that the average length of detox is fewer than eight days. However, certain substances like methadone and buprenorphine may take longer to clear because the drugs are relatively long acting. In these instances, patients often undergo a slow tapering of the abused substance, which can necessitate longer durations.
What are the dangers of detoxing alone?
It is possible to detox alone; however, it is not always ideal. Complications may arise at any time based on the substance used and the person’s existing physical and mental health. Also, intense cravings and other significant discomforts may arise during the withdrawal process, weakening the resolve to quit and potentially contributing to the risk of relapse.
The process of withdrawal can result in a wide array of symptoms that, depending on the drug and the individual, may include:
- Insomnia or hypersomnia.
- Nausea and vomiting.
- Diarrhea and other gastrointestinal distress.
- Appetite changes.
- Irritability and agitation.
- Strong drug cravings.
Medical detox may be better able to manage and treat symptoms such as these as they present – making the process as safe and comfortable as possible.
How are medications used in detox?
Medications are used to ease the process by improving comfort and stability. Increased comfort is linked to improved outcomes and longer periods of recovery. Medications are given more often to manage the withdrawal syndrome associated with opioids, alcohol, and sedatives. Some of the medications used in these situations include:
- Benzodiazepines (Valium, Xanax, Ativan, Klonopin) – These substances may be administered to those detoxing from alcohol as a measure to prevent seizures associated with acute withdrawal.
- Methadone/buprenorphine – Even though these substances are opioids themselves, they are approved to ease the symptoms of opioid withdrawal. These substances provide mild opiate effects but because they are longer-lasting in the body, they don’t provide the full euphoric highs or debilitating lows that come with drugs like heroin.
- Clonidine – This medication, which is routinely prescribed to lower blood pressure, is used to relieve some unpleasant withdrawal symptoms without producing a high or any intoxicating effects during opioid detox (it can be a helpful during nicotine detox as well).
After the completion of detox, certain medications may be used in conjunction with long-term treatment efforts. These pharmaceutical agents have various mechanisms of action, but each may help with relapse prevention. They include:
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Where does detox take place?
Detox can take place in a range of settings from someone’s home in the case of social detox to a rigidly-structured inpatient hospital setting. There are five recognized formal situations, as outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA):
- Level I – Detox progresses with visits to a doctor’s office or by visits from a home health agency checking on the patient at scheduled intervals.
- Level II – Detox takes place as part of a day program with increased opportunities for treatment interventions and observation.
- Level III – A nonmedical/ social detox setting that stresses the need for peer and social support. Appropriate for those whose withdrawal syndrome is severe enough to require some social support, but not severe enough to require strict medical supervision.
- Level IV – Completed in a detox center, this level will provide 24-hour medical services and supervision.
- Level V – Completed in an inpatient medical or psychiatric center, this level will provide intensive 24-hour acute care for the riskiest situations.
Placement at the appropriate level of care will be important for optimal benefit. Treatment will be completed in the least-restrictive environment, which means that someone should not be placed in a higher level unless it is medically necessary.
What is rapid or ultra-rapid detox?
Rapid and ultra-rapid detox focus on completing the withdrawal process as quickly as possible to shorten the total time:
- During rapid detox, the patient is given medication to speed up the onset of withdrawal and next given a number of medications to manage the resulting withdrawal symptoms in the hope of minimizing patient discomfort throughout the abbreviated detox duration.
- During ultra-rapid detox, the patient is put under general anesthesia when withdrawal symptoms are at their peak. Theoretically, when the patient recovers from the anesthetic and wakes, the majority of uncomfortable symptoms have already passed.
Each method has various risks including:
- Higher intensity of withdrawal symptoms.
- Higher treatment dropout rates due to the intensity of the symptoms experienced.
- Potentially unnecessary exposure to a number of additional pharmaceutical agents, each with differing safety profiles.
- Potential worsening of psychological symptoms.
- Possibility of delirium development in the detoxing individual.
- Lack of positive information related to long-term benefits.
These methods remain quite controversial since the risks often outweigh the potential benefits. Someone considering either of these treatments should research and fully understand the protocol and likely consequences. The National Institute on Drug Abuse reports that there are no findings to indicate that rapid and ultrarapid detox are more effective and also indicate that use of these methods may cause harm in certain circumstances.
What happens after detox?
At the end of detox, staff will generally try to link the patient to follow-up treatments for substance use and mental health concerns.
It is an important step in substance use treatment and sets the stage for recovery, but it does not represent complete treatment for addiction or drug dependence.Professionals will recommend and refer patients to appropriate treatments based on:
- Their success during detox.
- Their commitment to recovery.
- The presence of co-occurring mental or medical health issues.
- Their level of support at home.
- Their ability to attend and afford various treatment programs.
Possible referral options include:
- Ling, W., Hillhouse, M., Domier, C., Doraimani, G., Hunter, J., Thomas, C., . . . Bilangi, R. (n.d.). Buprenorphine tapering schedule and illicit opioid use. Retrieved March 13, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150159/
- Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). (n.d.). Retrieved March 13, 2016, from https://www.drugabuse.gov/sites/default/files/podat_1.pdf
- Study Finds Withdrawal No Easier With Ultrarapid Opiate Detox. (2006). Retrieved March 13, 2016, from https://www.drugabuse.gov/news-events/nida-notes/2006/10/study-finds-withdrawal-no-easier-ultrarapid-opiate-detox
- Treatment Approaches for Drug Addiction. (n.d.). Retrieved March 13, 2016, from https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction
- Treatment, C. F. (n.d.). Detoxification and Substance Abuse Treatment. Retrieved March 13, 2016, from http://www.ncbi.nlm.nih.gov/books/NBK64115/