Detox

Length of Detoxification

Because detoxification often entails a more intensive level of care than other types of AOD treatment, there is a practical value in defining a period during which a person is "in detoxification." There is no simple way to do this. Usually, the detoxification period is defined as the period during which the patient receives detoxification medications.

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Third-party payers often manage payment for AOD detoxification services separately from other phases of drug treatment, as though detoxification occurs in isolation from drug treatment. In clinical practice, this separation cannot exist. Detoxification is one component of a comprehensive treatment strategy.
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Another way of defining the detoxification period is by measuring the duration of withdrawal signs or symptoms. However, the duration of these symptoms may be difficult to determine in a correctly medicated patient because symptoms of withdrawal are largely suppressed by the medication. Chapter 3 describes the typical lengths of regimens for withdrawal.

The Role of Detoxification in AOD Abuse Treatment

For many AOD-dependent patients, detoxification is the beginning phase of treatment. It can entail more than a period of physical readjustment. It can also be a time when patients begin to make the psychological readjustments necessary for ongoing treatment. Offering detoxification alone, without followup to an appropriate level of care, is an inadequate use of limited resources. People who have severe problems that predate their AOD dependence or addiction -- such as family disintegration, lack of job skills, illiteracy, or psychiatric disorders -- may continue to have these problems after detoxification unless specific services are available to help them deal with these factors (Gerstein and Harwood, 1990).

Immediate Goals of Detoxification

To provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug free. Many risks are associated with withdrawal, some influenced by the setting. For persons who are severely dependent on alcohol, abrupt, unsupervised cessation of drinking may result in delirium tremens or death. Other sedative-hypnotics may produce life-threatening withdrawal syndromes. Withdrawal from opioids produces severe discomfort, but is not generally life threatening. However, risks to the patient and society are not limited to the severity of the patient's physical disturbance, particularly when the detoxification is conducted in an outpatient setting. Outpatients experiencing withdrawal symptoms may self-medicate with street drugs. The resulting interaction between prescribed medication and street drugs may result in an overdose. Less severe side effects include sedation or a drop in blood pressure.

To provide withdrawal that is humane and protects the patient's dignity. A caring staff, a supportive environment, sensitivity to cultural issues, confidentiality, and the selection of appropriate detoxification medication (if needed) are all important to providing humane withdrawal.

To prepare the patient for ongoing treatment of his or her AOD dependence. During detoxification, patients may form therapeutic relationships with treatment staff or other patients, and may become aware of alternatives to an AOD-abusing lifestyle. Detoxification is an opportunity to offer patients information and to motivate them for longer term treatment.

Repeated Detoxification

Alling discussed detoxification and treatment in a text published in 1992:

Those not familiar with the chronic nature of addictive disorders often characterize detoxification programs as 'revolving doors' through which patients come and go in an endless cycle, and which have little or no impact on the recovery process. Although it is true that many people undergo detoxification more than once -- and some do so many times -- the assumption that little or no progress has been made is often false. (Alling, 1992)

Alling(1992) described a pattern in individuals who return for several detoxification episodes, observing that young people with a history of AOD dependence of short duration (a year or less) "often are unrealistically optimistic about being able to remain drug free following detoxification." When recently AOD-dependent persons return after several months for repeat detoxification, it is usually with a more realistic expectation about what is needed to remain free from AODs. Individuals who subsequently relapse and return for detoxification a third time may have an even clearer understanding of what is required to sustain recovery (Alling, 1992).

During certain expected and predictable phases of recovery, addicted persons are at increased risk of relapse. However, relapse can occur at any point in recovery. Thus, relapse prevention is a legitimate area for patient education, and the relapsed patient is appropriate for clinical treatment. Treatment services designed precisely for this stage of the disease may facilitate the individual's return to abstinence.

Issues in Postdetoxification Treatment

Few addicted persons enter detoxification or seek further treatment with the idea of maintaining lifelong abstinence. They may still believe they can control their abuse of AODs. Some persons enter detoxification and other treatment to satisfy the demands of their families, employers, or the courts. They may be motivated to seek treatment because attempts to relieve pressure through other means have proved futile. Clinicians should consider patient motivation when deciding upon appropriate treatment placement.

Families suffer severe consequences from the AOD abuse of their loved ones. The consequences may include obvious problems such as lost income, domestic violence, or divorce. Less obvious consequences may also occur, such as issues concerning trust and children's mirroring maladaptive ways to deal with problems encountered in everyday living. Addiction is a family disease because of the seriousness of its effects on family members and family functioning. Just as the person who abuses AODs needs support, education, and counseling, so too does the family. It is appropriate and important for treatment providers to engage the family in treatment as early as possible, even while the individual is undergoing detoxification.

Effects of AOD Exposure and Withdrawal

Tolerance and Physical Dependence

Continued exposure to AODs induces adaptive changes in an individual's brain cells and neural functioning. The changes vary depending on the drug of abuse and are not completely understood. The term "neuroadaptation" is often used to refer to these changes. One result of neuroadaptation is drug tolerance; that is, increasing the amounts of the drug that are required to produce the same effect. A second consequence of neuroadaptation is physical dependence; the brain cells require the drug in order to function.

Drug Withdrawal

Sudden removal of alcohol or another drug of abuse from the system of a person who is physically dependent produces either an abstinence or withdrawal syndrome. The abstinence syndrome for each drug follows a predictable time course and has predictable signs and symptoms. Signs are defined by Webster's Medical Dictionary as "objective evidence of disease especially as observed and interpreted by the physician rather than by the patient or lay observer." Symptoms are defined in the same text as "subjective evidence of disease or physical disturbance observed by the patient."

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There are three immediate goals of detoxification:

• To provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug free
   
• To provide withdrawal that is humane and protects the patient's dignity
   
• To prepare the patient for ongoing treatment of his or her AOD dependence

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The signs and symptoms of drug withdrawal are usually the reverse of the direct pharmacological effects of the drug. Heroin use commonly produces elevation of mood (euphoria), a decrease in anxiety, insensitivity to pain (analgesia), and a decrease in the activity of the large intestine, often causing constipation. Heroin withdrawal, on the other hand, produces an unpleasant mood (dysphoria), pain, anxiety, and overactivity of the large intestine, often resulting in diarrhea. Alcohol usually reduces anxiety and causes sedation; large quantities may produce sleep, coma, or even death by respiratory depression. In a person who is physically dependent, cessation of alcohol use produces anxiety, insomnia, hallucinations, and seizures.

For short-acting drugs such as alcohol and heroin, the most severe signs and symptoms of withdrawal usually begin within hours of the individual's last use. With a long-acting drug or medication, such as diazepam (Valium), withdrawal symptoms may not begin for several days and usually reach peak intensity after 5 to 10 days. The most severe drug-withdrawal symptoms, during the initial stages of detoxification, constitute the acute abstinence syndrome. The adjective "acute" distinguishes the syndrome from a "chronic" or protracted abstinence syndrome, in which signs and symptoms of withdrawal may continue for weeks to months after cessation of use (Martin and Jasinski, 1969).

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The signs and symptoms of drug withdrawal are usually the reverse of the direct pharmacological effects of the drug.
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Protracted abstinence syndrome is the subject of considerable controversy. Providers often find it difficult to distinguish symptoms caused by drug withdrawal from those caused by a patient's underlying mental disorder, if one is present. The signs and symptoms of protracted withdrawal are not as predictable as those of acute withdrawal. Some patients may be predisposed to a protracted withdrawal. Acute withdrawal syndromes produce measurable signs that researchers can study in animals under controlled laboratory conditions; protracted withdrawal in patients, by contrast, is often confined to distress symptoms that cannot be studied in animals.

Source: U.S. Department of Health and Human Services

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