Withdrawal Medications: Making Detox Safe
The detox process allows a person’s system to slowly eliminate substances, such as drugs, and recover relatively normal functioning in the absence of these substances.
Most of the elimination of drugs from a person’s body occurs through the liver where they are metabolized and then excreted; however, there are very small amounts that are eliminated via other routes, such as perspiration, through the lungs, etc.
Why Detox Is Needed
Because the natural inclination of any system is to attempt to maintain a relative level of functioning that is consistent (homeostasis), when a person uses certain types of drugs for any period of time on a consistent basis, the system readjusts its set points for certain levels of substances, such as hormones and neurotransmitters, and adjusts its rate of functioning to adjust for the levels of the drugs in the tissues.
The longer a person takes certain substances, the more the person’s system becomes accustomed to them, and the person needs more of the substance to produce similar effects that were once produced at lower doses (tolerance).
As the person takes more of the substance in an attempt to get the effects they got at lower dosages, this person’s system also keeps readjusting.
When the person is unable to get the drug or decides to quit, and the levels of the drug in the system drop sharply, the system is thrown out of balance. When this happens, the person will inevitably experience some negative effects (withdrawal). When an individual has developed both tolerance and the potential for withdrawal symptoms, they have become physically dependent on the drug.
Having physical dependence on a drug may or may not be a sign of a formal substance use disorder; however, when it occurs, it does make the process of discontinuing the drug much more complicated. Because many withdrawal symptoms are extremely uncomfortable, the person will begin to crave their drug(s) of choice, and relapse rates for people going through the withdrawal process are high. One way to reduce the probability that someone will relapse is to provide medically assisted treatment during the withdrawal process.
Many individuals who qualify for diagnoses of substance use disorders and who attempt to negotiate the detox process will experience some withdrawal symptoms.
Certain drugs, such as alcohol, benzodiazepines, and opioid medications, are associated with extremely uncomfortable physical and emotional withdrawal symptoms, and in some cases, these symptoms can even be life-threatening.
Other drugs, such as cocaine, other stimulants, and marijuana, have unpleasant withdrawal effects that are primarily emotional but also may include some physical symptoms. This article will present a brief overview of the medications used during the detox process to assist with withdrawal and the overall process of getting off drugs.
There are several issues one should consider when attempting to detox from any drug:
- First, the early stages of recovery that include the detox process are often very difficult, and many individuals will relapse during this period. Chances of going through a successful detox are highly increased if one enlists the assistance of a medical professional, such as an addiction physician or psychiatrist who can provide medically assisted treatment during the detox process and reduce the chances of relapse.
- Second, for individuals who have moderate to severe substance use disorders that involve alcohol or benzodiazepines, the physical withdrawal process from these drugs can bring potentially fatal complications. It is not recommended that anyone with a substance use disorder that involves these drugs attempt to detox on their own.
- While the physical withdrawal symptoms from many other classes of drugs may not be potentially fatal, there are always serious emotional issues during the detox process, and individuals are often at risk for self-harm due to accidents, poor judgment, and even depression and suicidality. For that reason, anyone attempting to detox from any type of substance should consult with a physician trained in addiction medicine or psychiatry before undertaking the process.
- Finally, it is not suggested that individuals engage in rapid detox protocols, as these are not considered to be safe by many medical professionals. Instead, it is strongly suggested that individuals discuss going through detox with a licensed addiction medicine professional before attempting to engage in the detox process.
As the saying goes: “It is far better to be safe than sorry.” People with substance use disorders should get professional help when attempting to go through detox. In addition, the use or administration of any of the medications mentioned in this article should only be done under the direct supervision of a qualified physician. No one should attempt to use these medications without being under strict medical supervision.
Different Medications for Different Withdrawal Syndromes
Many of the medications that are used during the detox process can be used for different types of drugs. The rest of this article will discuss some specific medications that are used in specific instances for detox from certain classes of drugs. Individuals who have specific questions regarding specific withdrawal protocols regarding substances not mentioned in this article are encouraged to contact a local addiction medicine physician. Medications used during the detox process are typically designed to:
- Reduce withdrawal symptoms that occur during detox
- Reduce any potentially dangerous physical complications that can occur during withdrawal
- Reduce the cravings that will inevitably occur during the withdrawal and detox process
- Address any specific symptoms that may need to be controlled
- Address other symptoms associated with co-occurring disorders, such as depression, bipolar disorder, schizophrenia, personality disorders, etc.
- Detox from Benzodiazepines and Barbiturates
- These classes of drugs are generally considered to be central nervous system depressants, meaning that they slow down the functioning of the central nervous system, which in effect slows down the person’s bodily functions. They are typically used to control severe anxiety and seizures, and to act as sleep aids and/or muscle relaxants. Many have other off-label uses.
Sometimes, these drugs are also used to help individuals go through the detox process from a severe alcohol use disorder (see below). Some well-known benzodiazepines include Valium, Xanax, Klonopin, and Ativan, whereas some well-known barbiturates include Seconal, Nembutal, and drugs that contain phenobarbital such as Luminal.
Both of these classes of drugs are considered to have the potential for abuse and addiction, and they are extremely prone to the development of physical dependence. In addition, people who have developed severe substance use disorders to either of these classes of drugs may develop potentially fatal seizures during the withdrawal process. As a result, there are several strategies that physicians use during the detox process.
- A tapering strategy is a strategy that is often used during the detox process for many different types of drugs. The person with the substance use disorder is given slowly decreasing dosages of the drug on a fixed schedule, so the individual’s system can adjust slowly to the diminishing amounts of drugs present. Physicians have to design a tapering strategy based on both the general protocols described in research literature and individual differences, such that the person being treated is allowed to experience as few withdrawal symptoms as possible. Other medications to deal with issues like nausea, headaches, and even symptoms of anxiety can be given.
- For some people who are addicted to benzodiazepines or barbiturates that are shorter-acting, physicians can use a longer-acting benzodiazepine (e.g., Klonopin) and use a tapering process with that drug. The longer-acting drugs in these classes remain in the system for longer periods of time, and their effects are not as strong. This allows for a much more controlled tapering strategy.
- BuSpar is a drug that is used to treat anxiety. Buspar primarily works on the neurotransmitter serotonin and not the neurotransmitter GABA (the neurotransmitter that benzodiazepines and barbiturates affect), and it does not have the same potential for the development of physical dependence. Individuals going through detox from benzodiazepines and barbiturates who experience significant anxiety can be given BuSpar to deal with the emotional effects of the detox process.
- Flumazenil is a drug that can be used to treat benzodiazepine overdose and also can be used to lessen the effects of withdrawal from benzodiazepines and barbiturates. This drug is often given by injection.
Narcotic or opiate drugs have a very strong potential to develop physical dependence in anyone who takes them for more than a few weeks. The drugs in this category are synthesized or developed from substances taken from the poppy plant. There are many familiar drugs in this category, and many of these drugs are commonly abused. Some of the better-known drugs include morphine, heroin, OxyContin, and Vicodin (there are many others). The major medicinal use of these drugs is for pain control; however, there are other uses as well. These drugs also produce significant feelings of euphoria, and this results in many individuals using them for purposes other than pain control.
Unlike withdrawal from benzodiazepines and barbiturates, withdrawal from opioid drugs, while extremely uncomfortable, is not considered to be potentially fatal. Nonetheless, the withdrawal process from these drugs is so uncomfortable and emotionally distressing that individuals with severe opiate use disorders are candidates for potential harm due to accidents or even suicidality. In addition, the acute withdrawal effects from these drugs are so severe that the potential for relapse in individuals attempting to go “cold turkey” is extremely high. There are various medications that can assist the withdrawal process from opiates.
- Methadone is a familiar narcotic drug that is used to reduce cravings and to attenuate the withdrawal symptoms from narcotic drugs, particularly heroin.
- Buprenorphine is a drug that is used to control withdrawal symptoms and reduce cravings for opioid drugs. It is also the major ingredient in familiar drugs, such as Suboxone and Subutex, that can also be used to assist with withdrawal from narcotic drugs.
- Naltrexone is a drug that reduces cravings for many different types of drugs, but it is particularly useful in reducing cravings for narcotic medications.
- Naloxone is a drug that blocks the receptors for narcotic medications. It is commonly used in cases of overdose on opioid drugs, but is also a component in drugs like Suboxone to prevent people from abusing opiates.
- Certain types of antidepressant medications, such as desipramine, have been found to be useful in reducing cravings for narcotic drugs.
- Other drugs can be used to address specific symptoms, such as nausea, anxiety, fever, etc. For example, Neurontin (gabapentin) may be used in some instances to control withdrawal symptoms and cravings.
Some of the above medications, such as methadone and Suboxone, are also potential drugs of abuse, and these drugs need to administered by a physician. When the individual going through detox uses these drugs, a tapering strategy is often used to allow the person to slowly detox with as few withdrawal symptoms as possible. However, in some cases of methadone use, there is no tapering strategy, and many individuals are maintained on methadone indefinitely if they have chronic histories of relapse.
Drugs to Assist with Withdrawal from Alcohol
The withdrawal process from alcohol is particularly complicated. Chronic use of alcohol will result in physical dependence, and the symptoms of withdrawal from alcohol can be potentially fatal due to seizures. For individuals with moderate to severe alcohol use disorders, attempting to predict who might develop severe withdrawal symptoms, such as hallucinations, confusion, and seizures, is impossible. Thus, anyone with a long-term alcohol use disorder is encouraged to discuss their drinking habits, experiences when they were not drinking for a period of time, and any symptoms of withdrawal that they may have experienced in the past with an addiction medicine physician before attempting to discontinue alcohol use.
There are number of different medications that can be used to assist with the detox process from alcohol.
- Benzodiazepines are useful in the detox process from alcohol. These drugs should only be administered under the care of a licensed physician for this purpose, as they are also potential drugs of abuse and can be potentially fatal in overdose. A number of different benzodiazepines have been used, such as Valium, Librium, and others. A tapering strategy is used with these medications. Benzodiazepines reduce the severe symptoms of alcohol withdrawal, control any potential seizures, and are therefore consider the first line treatment strategy for withdrawal from alcohol.
- A number of different studies have suggested that anticonvulsant medications, such as Depakote and Tegretol, might be useful during alcohol withdrawal.
- Antabuse is a medication that results in a severe reaction when someone drinks alcohol. While it is not effective for the withdrawal symptoms from alcohol, it may be given in instances where the treatment team seeks to further protect against potential relapses.
- Naloxone can also be given to reduce cravings for alcohol.
- Certain beta blockers, such as atenolol and propranolol, have also been shown to reduce cravings for alcohol during the detox process.
- The drug baclofen, a muscle relaxant, has been shown to reduce cravings for alcohol.
- Other drugs for specific symptoms, such as insomnia or nausea, can be given as needed during the detox process.
Withdrawal from Stimulants
Stimulant medications speed up the central nervous system and, as a result, speed up the person’s entire functioning. The detox process from stimulants can be very distressing; however, it is generally not considered to be potentially dangerous as in the case of alcohol withdrawal. In rare cases, there can be potentially dangerous complications, including hallucinations and seizures, especially if stimulants are regularly abused with other drugs.
Medications used for individuals going through detox from stimulants, such as cocaine, Ritalin, Adderall, methamphetamine (crystal meth), or other amphetamines, are typically designed to manage specific symptoms and/or cravings. There is typically a period of depression or irritability during the withdrawal process that might lead to the potential for accidents or self-harm.
- Medications to control severe psychological symptoms, such as hallucinations or paranoia, may be used.
- A tapering strategy using benzodiazepines can be helpful.
- Long-term use of stimulants may lead to cardiovascular issues, such as increased heart rate or high blood pressure, and these may require specific treatment during the detox process.
- Many individuals who discontinue stimulant use experience severe emotional symptoms, such as depression, apathy, etc. Specific medications can be used in these instances at the discretion of the physician, such as antidepressants (although these often take a while to begin working), mild stimulants (of course, these should be used only under the supervision of a physician), and other drugs to target specific symptoms.
- Medications to control with insomnia may be used. Mild stimulants, such as modafinil, to assist individuals who become extremely lethargic may be used.
- In rare cases, individuals may develop seizures from stimulant abuse, especially if they mix stimulants with other drugs such as alcohol. Anticonvulsant medications can be used for seizure control.
- Drugs that can reduce cravings, such as naloxone, Suboxone, desipramine, and others, can also be useful during stimulant detox.
A number of different protocols might be used during the detox process. As mentioned above, for some individuals undergoing detox from narcotic medications, the anticonvulsant and pain reliever Neurontin (gabapentin) may be used, although there is no FDA approval for its use in this context. This and other medications may or may not be used, depending on the context, the physician, and the specific symptoms that the individual is experiencing.
There are a number of different drugs that can be used to address specific symptoms. Of course, in many cases, individuals might have developed physical dependence on combinations of drugs, such as benzodiazepines and alcohol, and this can complicate the detox process. The actual choice of the medical protocol used during the detox process depends on the patient, the clinic, and the physician. Anyone attempting to discontinue the use of any drug after chronic use should consult with a physician trained in addiction medicine to fully understand their options for detox.