- PAGE CONTENTS
- Withdrawal defined
- Withdrawal is the first step before treatment can begin
- Withdrawal is NOT treatment
- Withdrawal and substance-related disorders
- Cocaine and substance induced disorders
- Seizures during the withdrawal process
- The cumulative effect of withdrawal management
- The importance of medically-supervised alcohol withdrawal management
- The challenge of opiate drug withdrawal
- Skin detoxification
- The growth in popularity of home withdrawal management
- Withdrawal management can be distinguished by levels of care
- Rapid withdrawal for opiate addiction
- When medical and social detox services are combined
Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the US Department of Health and Human Services, defines withdrawal management as “ a set of interventions aimed at managing acute intoxication and withdrawal. Supervised withdrawal management may prevent potentially life-threatening complications that might appear if the patient was left untreated.”
Withdrawal Management is also designed to reduce the intensity of withdrawal symptoms for those that want to begin drug and alcohol treatment. For some patients it represents their point of first contact with treatment.
WITHDRAWAL MANAGEMENT IS NOT DRUG AND ALCOHOL TREATMENT OR REHABILITATION
Drug and alcohol treatment involves services designed to promote recovery for individuals struggling with substances. A simple way to distinguish between withdrawal management and treatment is that withdrawal management assists patients with physical dependence to drugs and/or alcohol while treatment assists clients with the psychological aspects of addiction.
Substance related disorders are those directly related to the taking of a drug of abuse, including alcohol, over the counter and prescription medications. The term substance can refer to a drug of abuse, medication or a toxin.
Substance related disorders are divided into two groups:
- Substance Use Disorders (substance dependence and abuse)
- Substance Induced Disorders (intoxication, withdrawal, delirium, persisting dementia, persisting amnesia, persisting psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction and sleep disorder)
Symptoms generally occur at high doses with over the counter or prescription medication and dissipate when the dosage is lowered or the medication is stopped. Withdrawal from chronic substance abuse can be life threatening.
Symptoms usually disappear when the substance is no longer present in the person’s system, but the resolution of those symptoms can take weeks or months and require treatment. Anxiety, hallucinations, psychosis and delusions may occur. Impairment in mood and thought processes such as reasoning, retention and recall are the most common symptoms of intoxication and the persistent. Depending on length of abuse and the substance of choice, these symptoms can become permanent.
Approximately two percent of those experiencing cocaine induced psychosis recover fully. Anxiety disorders and depressive illness (not present before a psychotic episode) are the most common psychiatric illnesses people may suffer from following a psychotic break. Others are not so fortunate and do not recover from a psychotic state, and may require long term supported care.
Alcohol, Benzodiazepines (Valium, Ativan) and Phenobarbital (Tuinal, Seconal) can cause seizures during the detox process. Medically supervised detoxification is essential to monitor health status, and reduce health risks.
Each subsequent withdrawal tends to be more intense, require more support and longer physical recovery time. Damage to the body is incremental with each detox and withdrawal.
Psychiatric symptoms can worsen or suddenly develop during detox and withdrawal and may not abate on physical recovery.
Many people assume that because alcohol is commonplace in society that risks associated with alcohol abuse are not as serious as illicit drugs such as cocaine and heroine. When it comes to withdrawal management, however, the risks associated with sudden withdrawal are actually higher with alcohol.
Medically-supervised alcohol withdrawal is often necessary to deal with symptoms of alcohol withdrawal which can range from mild tremors to severe convulsions. Alcohol withdrawal can be life-threatening if adequate supervision by trained medical professionals is not provided.
Please see the Alcohol section for additional information on the effects of alcohol.
Source: Myrick, Hugh; Anton, Raymond, Treatment of Alcohol Withdrawal, The Physicians’ Guide to Helping Patients with Alcohol Problems. National Institute on Alcoholism and Alcohol Abuse (NIAAA).
An opiate is a central nervous system depressant that takes many forms with the most common being illicit drugs such as heroin and opium and pain killer medication such as Oxycontin ®, Percocets ® and Vicodin ®.
Opiate withdrawal is difficult for many individuals who may be unwilling or unable to deal with flu-like symptoms such as diarrhea, goose bumps, abdominal pain, sweating, nausea and vomiting (many of our clients describe it as experiencing the worst hangover you can possibly imagine).
Please see the Methadone section for additional information on opiate withdrawal.
Approximately 10 percent of the elimination of toxins in the body occurs through the skin, working in conjunction with internal organs such as the colon, kidneys and lungs. Various methods of skin detoxification include skin brushing, contrast showers (hot then cold), mineral supplements and water and also the use of sauna (infrared sauna) and ozone therapy.
Sunshine Coast Health Centre utilizes infrared sauna as a therapy to help clients with relaxation and detoxification. See the therapy section of this website for more information on sauna therapy and massage therapy at Sunshine Coast Health Centre.
Home detox (sometimes called daytox) is a method of delivering withdrawal management services on an outpatient basis rather than the traditional admission to a hospital, stand-alone medical detoxification facility or residential treatment centre with an integrated withdrawal management.
Clients continue to be monitored by qualified medical personnel but return home between visits to a medical clinic or hospital. The government likes the idea of home detox because it does not tie up hospital beds and individuals suffering from alcohol or drug withdrawal often prefer home to being surrounded by strangers in unfamiliar surroundings. Patients are usually provided a contact number where a medical practitioner can be contacted if necessary.
Individuals with a pre-existing medical condition or mental illness are not suitable candidates for home detox. Rather, a monitored facility staffed 24 hours 7 days a week by trained medical personnel is recommended.
The American Society of Addiction Medicine provides a set of guidelines that list levels of care based on the severity of an addiction and related problems. Criteria are also included which attempt to match a patient’s severity of illness with five intensities of detoxification service.
Adult Detoxification Levels of Care*
Level I-D: Ambulatory Detoxification Without Extended Onsite Monitoring
Comment: a doctor’s office or community health clinic is an example of this level of care.
Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring. This level of care is monitored by appropriately credentialed and licensed nurses.
Comment: home detox or daytox is an example of this level of care as a patient may come to a hospital or stand-alone detox during the day but return home overnight.
Level III.2-D: Clinically Managed Residential Detoxification. This level is intended for patients whose intoxication and/or withdrawal is sufficient to warrant 24-hour support.
Comment: social detox or non-medical detox is an example of this setting. Monitoring provided a peer group or by support staff with little or no medical training.
Level III.7-D: Medically Monitored Inpatient Detoxification. Unlike Level III.2.D, this level provides 24-hour medically supervised detoxification services.
Comment: a freestanding detoxification center (not connected to a hospital) or detox integrated with a residential drug and alcohol treatment center would be examples of this level of care. Medical detoxification services ensure that each patient has an appointment with a physician and is provided around-the-clock monitoring by nursing staff. Sunshine Coast Health Centre is an example of this level of care.
Level IV-D: Medically Managed Intensive Inpatient Detoxification. This level provides 24-hour care in an acute care inpatient setting.
Comments: an inpatient psychiatric ward in a hospital would be an example of this level. Patients that have moderate to severe mental illness that is not stabilized OR patients that have a pre-existing medical condition that is complicating efforts at detoxification would be referred to this level of care. Powell River General Hospital is an example of this level of care.
*Source: American Society of Addiction Medicine (ASAM), Patient Placement Criteria, Second Edition, Revised (PPC-2R)
Rapid detox (also known as rapid detoxification under anaesthesia or RODA) is a process that helps individuals withdrawal faster opiates such as methadone, Oxycontin, heroin. Withdrawal from opiates is a difficult process for many who are unwilling or unable to tolerate opiate withdrawal symptoms. There are two types of rapid detox which can be distinguished by the level of sedation: rapid opioid detoxification (ROD) where mild sedation is provided orally (by mouth) and ultra rapid opioid detoxification (UROD) where heavy sedation is administered intravenously (through the veins). Oral sedation is the recommended procedure for the vast majority of rapid detox centers.
Currently, rapid detox is not covered by provincial health insurance in Canada or most insurance plans in the United States. Rapid detox is an outpatient procedure that usually takes 6 to 8 hours and is typically provided in rapid detox centers as opposed to hospitals.
In Canada, It is important to note that, with any managed withdrawal or detox, a patient will still require treatment to deal with the psychological dependence of opiate addiction.
Rapid detox is a good option for individuals who are clearly motivated to make substantial changes in their lifestyle necessary to manage their addiction to opiates. Those considering rapid detox must also be prepared for admission to residential drug and alcohol treatment immediately following rapid detox. Since wait lists are common in most government-funded drug and alcohol treatment centers, individuals may want to consider privately-funded addiction treatment to ensure a successful transition.
Some withdrawal management services combine the elements of medical and social detox by employing the services of a physician while having monitoring provided by non-medical personnel such as care aides OR providing nurse monitoring with a physician on-call (appointments with a physician made only when deemed necessary).
If you anticipate that your withdrawal from drugs or alcohol is going to be difficult, make sure you obtain specific information on the level of supervision and the qualifications of the staff that will be charged with your care while in withdrawal management.
I. PRINTED RESOURCES
II. ONLINE RESOURCES
Treatment Manuals for Withdrawal Management
Detoxification from Alcohol and Other Drugs (1995) Treatment Improvement Protocol (TIP) 19.has developed comprehensive guidelines for detoxification from alcohol and other drugs written from a panel of specialists in detoxification. Substance Abuse and Mental Health Services Administration (SAMHSA). DHHS Publication 95-3046.