Detoxification and Withdrawal Management

The process of detoxification involves the safe yet effective manner of reversing substance dependence in a person. Physiologically speaking, it refers to the process of decreasing the biological activity of drug dependence in the body. There are many different strategies for drug detoxification, the choice of which depends on factors such as the physician’s clinical judgment, the patient’s lifestyle, degree of dependence, and personal preference.
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The approach to drug detoxification may be medical or non-medical. Medical detoxification involves the use of medicines and other medical treatments to facilitate the process of detoxification and prevent or manage its complications. Medically assisted detoxification and withdrawal management is especially useful in the treatment of opioid dependence, but it is also beneficial for the management of addiction to other drugs.

Non-medical detox or “social” detox, on the other hand, allows the patients to withdraw from drugs at their own pace while under the care and supervision of medical professionals. It’s basically like going ‘cold turkey,’ but with the proper support systems in place. Unlike medical detox, social detox capitalizes on psychological and emotional support to help the patient while they recover from drug dependence or substance use disorder.

As mentioned, the right approach to drug detoxification and withdrawal management depends on several factors and differs from patient to patient. As medical complications and other situations may arise at any point during the process, appropriate adjustments may be recommended to optimize treatment

Why Is Detoxification Necessary?

Not all patients who undergo detoxification have necessarily been diagnosed with substance use disorder. For example, long-term treatment of chronic nonmalignant pain with opioids may require detoxification. Similarly, not all patients of substance use disorder need to undergo detoxification. The necessity for detoxification may arise after long-term use of any kind of drugs, whether prescription or illicit. Detoxification is necessary to avoid any adverse consequences of abrupt cessation or withdrawal from drugs.

Steps of Detoxification

Detoxification generally involves three essential steps or components.

Evaluation

Evaluation is the first step in the detoxification process. This serves as the basis for the subsequent treatment that the patient will receive.. The patient’s blood is tested for the presence of substances and their concentration. Screening for coexisting medical and psychiatric conditions is also done to help determine the appropriate treatment approach during and after detoxification.

Stabilization

Stabilization involves the process of assisting the patient through acute intoxication and withdrawal. In this step, medical and psychosocial services may be enlisted to attain a substance-free state for the patient. Although pharmacological intervention is almost always required in the stabilization stage, particularly in the management of withdrawal symptoms, the emotional and moral support of the patient’s family and friends are also very important elements in this step.

Supporting  entry into treatment

This step in the detoxification process helps  the patient get ready for entry into a substance abuse treatment program. The importance of completing the entire treatment program must be emphasized to the patient, especially to those who have a history of failing to follow through. A written treatment contract can be made available to encourage adequate follow through and to complete every step of the care continuum. This contract is not legally binding and is voluntarily signed by patients at the beginning of treatment.

Withdrawal Symptoms

In order to better understand withdrawal management, its benefits, and how it’s done, it is best to discuss withdrawal symptoms first. Withdrawal symptoms become present in the body when a person stops or reduces their intake of a substance, such as opioids or alcohol. The duration and intensity of withdrawal symptoms vary in each patient according to the severity of their dependence and the drug type, but they generally manifest as nausea and vomiting, diarrhea, anxiety, and insomnia.

Withdrawal Symptoms Associated With Specific Substances

Opioids 

  • Difficulty sleeping
  • Anxiety
  • Hot and cold flushes
  • Excessive sweating
  • Muscle cramps
  • Nausea and vomiting
  • Diarrhea

Nicotine 

  • Irritability
  • Easily angered
  • frustration
  • Anxiety
  • Depression
  • Difficulty concentrating
  • Increased appetite
  • Sleeplessness
  • Restlessness

Stimulants 

  • Agitation
  • Irritability
  • Depressed mood
  • Increased appetite
  • Increased time sleeping
  • Muscle aches

Cannabis 

  • Anxiety
  • Irritability
  • Restlessness
  • Poor appetite
  • Sleep disturbance
  • Nocturnal perspiration
  • Tremors

 

Benzodiazepines 

  • Anxiety
  • Sleeplessness
  • Restlessness
  • Agitation
  • Irritability

Alcohol

  • Anxiety
  • Excessive perspiration
  • Tremors, specifically on the hands
  • Increased heart rate
  • Increased blood pressure
  • Sleeplessness

Severe withdrawal may manifest as:

  • Seizures
  • Hallucinations
  • Delirium
  • Extreme agitation

 Withdrawal Management

Withdrawal management refers to the treatment of withdrawal symptoms. Treatment approaches for withdrawal symptoms range from medical care to psychological and psychosocial support. For many people who suffer from substance use disorders, withdrawal management facilities may be the first touchpoint for treatment.

Withdrawal management cannot be considered as a stand-alone treatment for substance abuse; rather, it is a crucial part of the overall management of substance use disorder. Most withdrawal management facilities offer more definitive treatment options such as opioid agonist therapy for opioid dependence and alcohol relapse prevention medications for alcohol dependence. In general, withdrawal management facilities provide medical assistance to patients of substance use disorder through close supervision and access to pharmacological options in order to prevent complications of withdrawal.

 Withdrawal Management of Specific Substances

 Opioids

 The management for opioid withdrawal typically depends on the severity of the patient’s withdrawal symptoms. Mild opioid withdrawal can be managed with proper hydration and vitamin supplementation coupled with symptomatic treatment as opioid withdrawal usually manifests as nausea and vomiting, muscle cramps, and insomnia. Moderate to severe opioid withdrawal necessitates medical care. Clonidine, buprenorphine, and methadone are some of the most commonly used medications in managing opioid withdrawal of this degree. These medications have the ability to reduce withdrawal symptoms and decrease cravings.

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Nicotine

 Nicotine replacement therapies (NRTs) are the first-line treatment for managing nicotine withdrawal. NRTs replace the nicotine from tobacco, thus preventing the development of withdrawal symptoms in the patient. Some of the approved formulations include transdermal nicotine patches, nicotine lozenges, nicotine inhalant spray, and nicotine gums. Behavioral therapies used as adjunctive treatment to NRTs also increase smoking cessation rates. Medications such as bupropion and varenicline also have proven benefits in managing nicotine withdrawal and improving quit rates.

 Stimulants

 Stimulants are psychoactive substances such as cocaine and methamphetamine. Patients who are experiencing symptoms of stimulant withdrawal must be closely monitored as they may develop complications such as anxiety and depression. There may also be increased risk of self-harm. Symptomatic treatment may be offered to address other concerns such as aches.

Some patients who have symptoms of stimulant withdrawal may develop psychotic symptoms such as hallucinations, paranoia, and agitation, which can present as dangers to the patient or to others. In this instance, behavioral management strategies may be employed. Diazepam may also be initiated in some cases. Severe agitation that is not adequately pacified by medications prompts transfer to a hospital care.

 Cannabis

 Cannabis withdrawal only manifests with mild symptoms and is best managed by providing psychosocial care. Patients must be placed in a secure, nurturing environment where adequate emotional and psychiatric support is available, as some patients may develop psychiatric disturbances in the process. Some of the complications of cannabis withdrawal include anxiety and dissociation. Close supervision of patients must be observed during therapy.

 Benzodiazepine

 One of the most effective methods of managing benzodiazepine withdrawal is tapering off. Abrupt cessation of benzodiazepine intake can cause life-threatening complications, so gradual reduction in the quantity and frequency of intake is instead recommended for patients. There are no hard and fast rules as to the process of tapering off; rather it depends on the starting dose, duration of therapy, tolerance of the patient, and the patient’s risk of relapse. Benzodiazepine substitution may also be done with the use of anticonvulsants such as carbamazepine and pregabalin, which have been proven to have modest benefit and without significant withdrawal symptoms. Flumazenil is also useful to some degree. The use of antidepressants and beta blockers have yet to be proven.

 Alcohol

Mild alcohol withdrawal can be managed through supportive care. The focus of treatment is alleviating symptoms and correcting metabolic derangements that could follow as consequences of long-term alcohol dependence. Multivitamin supplements, especially vitamin B1 must be given in order to prevent subsequent problems in cognitive functions. Benzodiazepines such as diazepam may be used to control agitation. Diazepam is used in cases of moderate alcohol withdrawal alongside supportive care, but patients must be monitored closely for excessive sedation. Diazepam is also the therapy of choice in severe alcohol withdrawal, although high doses may be required in order to achieve desired effect.

The process of detoxification and withdrawal management can be long and difficult for patients of substance use disorder. Patients should be placed in a safe and nurturing environment. Treating patients with utter compassion and understanding can be critical for a successful recovery. Caregivers, family, friends, and other significant people must extend care and empathy to the patients as they will be needing a great deal of moral and emotional support throughout the entire process of treating their addiction.

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