By : Nancy Merrill, PMHCNS, BC
Detoxification from alcohol and/or drugs is an important first step in recovery. However, it’s not only important to take that first step, but also to do it safely.
What Is Detoxification?
There are several types of medical detoxification (detox), including detox from alcohol, benzodiazepines, or opioids.
When someone requires alcohol detox, the patient’s alcohol intake is stopped fairly abruptly. In order to moderate the effects of this quick stoppage, we give them a medication that tempers less severe symptoms and helps prevent the more dangerous symptoms of withdrawal. The medications typically used for alcohol detox are all in the benzodiazepine family, including diazepam (Valium), chlordiazepoxide (Librium), lorazepam (Ativan), and oxazepam (Serax). Sometimes, detox for alcohol utilizes other classes of medications, such as anti-seizure medications and barbiturates.
Our detox program at McLean Hospital, the Alcohol and Drug Abuse Inpatient Program, starts with a 24-hour evaluation. During this time, we check the patient’s blood pressure, pulse, respiration, ability to walk and stand, and other factors to determine how much medication should be used at the outset. The dosage is then reduced significantly each day, and, in most cases, by the end of four to five days, the patient has been detoxed from alcohol.
In order to detox from benzodiazepines, the general approach is to gradually reduce the patient’s intake of benzodiazepines. Detoxing from benzodiazepines is typically a much lengthier process than detoxing from alcohol, often taking place over the course of weeks or several months as an outpatient. Vital signs will be monitored throughout treatment, and non-benzodiazepine medications may be used to reduce withdrawal discomfort.
For opioid detox, the standard approach is to replace the illicit opioids a patient is using with safely prescribed opioid medications, such as buprenorphine or methadone. At McLean, we use buprenorphine. The evidence supports maintaining patients on these medications for extended periods to stabilize recovery. However, for patients who decline this or do not have access to medication maintenance, opioid detoxification can be accomplished over four to fourteen days, depending on the medication used.
Potential Effects of Alcohol and Drug Withdrawal
The potential physical and psychological effects of benzodiazepine and alcohol withdrawal include shaky hands, sweating, mild to severe anxiety, nausea, vomiting, headaches, insomnia, and urges to drink or to take pills. Opioid withdrawal is similar but often also involves diarrhea, which can lead to dehydration as well as vomiting, chills, leg cramps, depression, watery eyes, runny nose, and a strong craving for opioids.
Severe cases of benzodiazepine and alcohol withdrawal may be life-threatening. Benzodiazepine withdrawal can lead to seizures, and severe cases of alcohol withdrawal can lead to seizures or delirium tremens (a life-threatening confusion state in which a person may experience hallucinations and distress).
After Completing a Detox Program
We recommend that patients continue with some type of therapy after completing a detox program and continue medication maintenance for opioid use disorder. Opportunities for therapy include intensive outpatient treatment (partial hospital/day programs), residential treatment, group therapy, individual therapy, or self-help groups, such as Narcotics Anonymous or Alcoholics Anonymous.
Patients may also be offered medication-assisted treatment to help them maintain their sobriety. For alcohol use disorders, naltrexone can be administered via a pill or an injection, and other approved treatments include acamprosate, disulfiram, and topiramate. For opioid use disorder, monthly doses of injectable naltrexone, buprenorphine, or methadone will reduce cravings and promote abstinence from opioid use. All medication treatments should be regularly monitored for effectiveness by a prescriber or care team.
Importance of Detox in a Medical Setting
I believe that safety, comfort, and effectiveness are the three most important reasons why detox should be performed in a medical setting.
In a medical detox setting, a patient gets 24-hour care. Nurses and doctors check vital signs, make sure that the patient’s blood alcohol level is coming down safely, evaluate liver function, and do whatever they can to make the patient feel as comfortable as possible. Nobody likes to suffer, so I think that this focus on safety and comfort gives people a leg up on their journey to recovery. By getting through this first step without feeling terribly uncomfortable, it helps to develop a mindset in patients that they can stay substance-free, that there truly is recovery at the end of the road.
Unfortunately, the vast majority of people who need treatment either try to detox on their own or fail to seek treatment at all. I think that a lot of factors contribute to this situation.
In some cases, there is a lack of accessibility—sometimes real and sometimes perceived. For instance, there may not be enough accessible treatment options in the area where the potential patient lives or their insurance may not adequately cover their needs.
Another hurdle is that most programs require abstinence, and not everybody wants to do that right away. These people may choose to try detoxing by slowly reducing their usage.
Other reasons include not understanding the medical risks of stopping on their own, frustration after a failed attempt at detoxing, and the lack of desire to get clean.
How to Know If I or Someone I Care About Needs Medical Detox
Simply put, anyone who is concerned about their own or a loved one’s drug or alcohol dependency should consider arranging a consultation. The need for a medical detox for alcohol depends on how much, how frequently, and how long they have been drinking, whereas for benzodiazepines, it depends largely on how long they have been using. For opioids, need is often determined by assessing an individual’s functionality instead of evaluating the nature of their usage.
For family members who are thinking about intervening, there are two things to consider. One is that when people are in the middle of addictive use, they’re typically not at their highest motivation level. This means that they might not get help without your encouragement.
I also tell families that it’s a dangerous myth that we have to wait until someone hits rock bottom before they are ready to get treatment. Don’t wait until someone hits rock bottom. That will just make the road to recovery harder.
It’s often not easy to encourage someone to get help, but the hard work is worth it. And it may not always be easy to access help, but it’s out there.
Nancy Merrill, PMHCNS, BC, is a psychiatric nurse and program director of the Alcohol and Drug Abuse Inpatient Program at McLean Hospital. For more than 40 years, McLean has been providing care for individuals with substance use disorders with and without other accompanying psychiatric conditions such as depression, anxiety disorders, bipolar disorder, and post-traumatic stress disorder. Learn more about McLean’s comprehensive psychiatric services by visiting McLean’s website.
If you are concerned about your own substance use or that of a loved one, the Substance Abuse and Mental Health Services Administration (SAMHSA) offers the Behavioral Health Treatment Services Locator, a confidential and anonymous source of information for persons seeking treatment facilities in the United States or US territories for substance abuse/addiction and/or mental health problems.
Need help with substance abuse or mental health issues? In the US, call 800-662-HELP (4357) for the SAMHSA National Helpline.