Detox Does Not Equal Treatment: Withdrawal Management and Treatment of Substance Use Disorders
Author: William S. Jacobs, MD
Many patients with a substance use disorder will be physically dependent on drugs they are taking and will experience withdrawal symptoms when they stop or reduce the amount they are using. For certain drugs, especially alcohol and sedatives (including benzodiazepines), this withdrawal syndrome potentially can be fatal.
The medical management of withdrawal syndromes was formerly known as detoxification, or detox. In many cases, withdrawal management is medically necessary before a patient can proceed with a formal treatment program. Even though withdrawal management may be necessary, that process is only a precursor to the actual substance use disorder treatment process.
Within substance use disorders, the class of drug influences the withdrawal experience, with many people assuming heroin withdrawal is the most painful and life threatening. That actually is not the case. Patients going through withdrawal for heroin or other opioids may think they are dying — and without appropriate medical treatment they may feel like they are dying — but opioid withdrawal rarely leads to death unless there was a serious underlying medical condition such as heart disease. Withdrawal from alcohol and sedatives like Ambien, Xanax, Ativan, Klonopin and Valium is much more likely to be life-threatening, especially if not appropriately medically treated. For this reason, it is important for people not to go cold turkey and attempt to detox at home when physically dependent on alcohol or sedatives. Even in a hospital setting with good medical care, the risk of dying from withdrawal from those substances can approach 7 percent.
In many cases, depending on the class of substance on which the patient is dependent, physicians can prescribe medications that relieve most withdrawal symptoms. If the long-term plan is for maintenance therapy for opioid addiction, they also may stabilize the patient on medicine such as methadone or buprenorphine.
The first phase of treatment begins when the patient enters a treatment facility for evaluation for a substance use disorder. Clinicians take the patient’s history of past and recent drug use, measure his blood alcohol level and test urine and saliva samples. A physical exam, including a mental status exam, along with additional lab testing, identifies evidence of intoxication, withdrawal or impending withdrawal, as well as any co-occurring medical issues that may be affected during withdrawal. Malnutrition and dehydration can exacerbate the effects of withdrawal; clinicians must identify and treat these maladies. The duration and severity of acute withdrawal symptoms varies depending on the class of drug and the amount, frequency, duration and potency of the drug or combination of drugs used as well as individual factors unique to each patient. Symptoms can last several days or even weeks.
Many patients mistakenly believe that simply stopping their drug use and getting through the withdrawal process equals treatment. That is only the first phase of treatment, which readies the patient for the actual process of learning to remain abstinent and to become healthy, happy and productive members of society. Going through the withdrawal process without continuing on to phase two almost always leads to relapse. In one study, researchers followed 100 patients who were successfully medically “detoxed” off methadone but did not receive any additional treatment. One year later, 99 patients were using opiates again. The one who did not attributed his success to a spiritual awakening.
Addiction is a chronic brain disease and should not be treated as an acute disease that can be cured. The only way to successfully treat a chronic disease is to provide treatment that will put the disease into remission and keep it there. Maintenance therapy is required for alcohol and drug addiction in the same way that it is required for a chronic disease such as diabetes. Diabetics can be treated in a hospital to normalize blood sugar levels, but if that patient goes home and does not continue maintenance therapy (by following diet and lifestyle restrictions, monitoring blood sugar levels, taking prescribed medicines and following up regularly with healthcare providers) the patient will either almost certainly end up back in the hospital or dead. For patients with substance use disorders, maintenance is the third phase of treatment following the successful completion of intensive therapy (phase two) preceded by the withdrawal management and initial assessment and stabilization of co-occurring medical and psychiatric conditions (phase one).
Patients must successfully complete these three phases to reach the desired goal of long-term recovery.