Detoxification From Alcohol and Other Drugs
Treatment Improvement Protocol (TIP) Series 19

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.

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.

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."

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).

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.

Drug Categories

Addiction specialists and researchers categorize drugs and medications into groups such as opioids, sedative-hypnotics, and stimulants. Drugs in each group are similar pharmacologically and produce a similar withdrawal syndrome. The term opiate refers to opium and derivatives of opium, a naturally occurring substance, that have effects similar to those of morphine. Drugs such as heroin and medications such as codeine are examples of opiates. The term opioid refers to all substances, both those derived from opium and those synthetically produced, that have effects similar to the effects of morphine. Examples of synthetic opioids include Demerol, Percodan, and methadone. Sedative-hypnotics are usually prescribed medications designed to reduce anxiety or facilitate sleep. They include barbiturates such as secobarbital (Seconal) and benzodiazepines such as diazepam (Valium) and alprazolam (Xanax). Alcohol shares many pharmacological characteristics with the sedative-hypnotics. Stimulants produce increased arousal accompanied by a sense of confidence and euphoria. This category of drug includes cocaine and methamphetamine.

All drugs in a given group produce a common withdrawal syndrome; however, the intensity and time span of the withdrawal varies, depending on the specific agent. The signs and symptoms of methadone withdrawal are similar to those of heroin withdrawal; however, the signs of heroin withdrawal begin relatively quickly and peak within 24 to 48 hours after the last dose. Methadone withdrawal symptoms begin more slowly, are less intense, and last longer.

The severity of withdrawal varies by drug group. Opioid withdrawal is unpleasant and distressing to patients, but it is not medically life threatening to a person who is otherwise physically healthy. On the other hand, withdrawal from alcohol or other sedative-hypnotics can produce grand mal seizures and a life-threatening disruption of physiology, even in a patient without other medical illness. Stimulant withdrawal is characterized by such symptoms as depression, and the primary risk during withdrawal is suicidal behavior.

After detoxification, the physiological functioning of the brain cells gradually returns to its predependent state; however, the cells may not be exactly the same as they were before dependence. Should a person who has undergone detoxification resume use of any drug in the same category as that upon which he or she has been physically dependent, neuroadaptation occurs more rapidly than it did the first time (Cochin and Kornetsky, 1964).

The Case for AOD Detoxification and Treatment

A number of forces are reshaping the delivery of AOD detoxification and treatment services. Some managed care systems and health insurance programs have curtailed substance use disorder treatment services. A challenge for those engaged in health care reform is to achieve a balance between high-quality care and cost-effective care. Most health insurance today is provided by employers. Employers and insurers will have more incentives to offer adequate AOD abuse treatment services as a standard benefit if they are educated about the treatable nature of addictive disease and the overall cost-effectiveness of treatment. The AOD abuse treatment system can be instrumental in providing this education. To do so, it will be necessary to substantiate the effectiveness of treatment. Careful research that generates solid data showing the benefits of treatment is the most powerful way to change negative perceptions.

Results were recently published of an important long-term study conducted by the California Department of Alcohol and Drug Programs on the effectiveness of AOD abuse treatment, the costs of treatment, and the economic value of treatment to society (California Department of Alcohol and Drug Programs, 1994). This 2-year study, called the CALDATA study, followed a rigorous probability sample of 1,900 individuals, representing the nearly 150,000 persons who received AOD abuse treatment in California in 1992. The sample included patients who received treatment in therapeutic communities, social model programs, outpatient drug-free programs, and methadone maintenance programs. The cost of treating the approximately 150,000 participants in 1992 was $209 million, while the benefits accrued during treatment and in the first year afterwards were worth approximately $1.5 billion. Thus, for every dollar spent on treatment, more than $7 in future costs were saved, most significantly in the area of crime. For a smaller sample followed through the second year, results indicate that longer range cumulative benefits of treatment will be substantially higher than shorter term benefits.

In a summary of the study, its authors listed the following findings under the heading Treatment Effectiveness:

• "Crime: The level of criminal activity declined by two-thirds from before treatment to after treatment. The greater the length of time spent in treatment, the greater the percent reduction in criminal activity.
• "Alcohol/drug use: Declines of approximately two-fifths also occurred in the use of alcohol and other drugs from before treatment to after treatment.
• "Health care: About one-third reductions in hospitalizations were reported from before treatment to after treatment. There were corresponding significant improvements in other health indicators.
• "Differences by substance: There has been concern that stimulants, and crack cocaine especially, might be much more resistant to treatment than more familiar drugs such as alcohol or heroin. However, treatment for problems with the major stimulant drugs (crack cocaine, powdered cocaine, and methamphetamine), which were all in widespread use, was found to be just as effective for treatment for alcohol problems, and somewhat more effective than treatment for heroin problems.
• "No gender, age, or ethnic differences: For each type of treatment studied, there were slight or no differences in effectiveness between men and women, younger and older participants, or among African Americans, Hispanics, and Whites."

Barriers to Care

Managed care criteria may present barriers to appropriate treatment. Inpatient treatment must be certified as medically necessary. For chemical dependency treatment, insurance providers often equate medical necessity only with the detoxification phase. Unless the patient has coexisting medical or psychiatric conditions, he or she is often removed from inpatient treatment when detoxification is complete.

Research appears to indicate that, at least in the long term, there are no significant differences between the outcomes for patients who are treated as inpatients and those who are treated as outpatients. Hayashida and colleagues (Hayashida et al., 1989) wrote that "Outpatient medical detoxification should be considered as an effective, safe, and cost-saving treatment alternative for persons with mild-to-moderate symptoms of alcohol withdrawal."

The impact of managed care on patient treatment outcome has not been studied adequately. The panelists were concerned that important clinical decisions affecting patient care were often driven by economic rather than clinical considerations. Skilled clinicians consider many factors other than a diagnosis of substance use disorder when deciding the level of care for a patient. Some examples of these considerations include whether the patient is living in a supportive, drug-free environment; whether there is a high level of family discord; whether the patient has significant psychiatric comorbidity; and whether the patient has access to appropriate transportation to and from the treatment facility.

Many AOD-abusing patients have inadequate treatment coverage and resources. If they relapse to AOD abuse following treatment, they may be fired and lose their health benefits. Because preemployment screening has become common, these individuals frequently are unable to find other jobs and thereby regain health insurance coverage. As a result, many AOD abusers are unemployed and have no health insurance. Their only treatment alternative is the public sector, which in most areas does not have the capacity needed to meet requests for services.

For AOD-dependent individuals, waiting periods and other barriers to treatment are countertherapeutic. An important facet of addiction is the individual's denial of the adverse effects of his or her AOD abuse. Many patients seek detoxification only during times of crisis: a drug-related seizure, an arrest, an illness of a family member, or the death of a friend. Patients who are physically dependent may recognize the need for detoxification, but they may or may not recognize the need for ongoing treatment. For AOD abuse treatment staff, a patient's crisis creates an intervention opportunity. During the crisis and its resolution, patients may be unusually receptive to consideration of lifestyle alternatives, education, and the need for longer term treatment.

Improving Access to Care

Health care reform, now on the political agendas of the Nation and the States, offers some avenues for improving access to treatment. Many populations, including the homeless, minority women, and nonregistered immigrants, have little access to treatment. Under some universal health coverage plans, more AOD-dependent persons would have access to treatment, and those with insurance would not be terminated from their policies if they relapsed.

A second area that holds promise for progress in AOD abuse treatment is the developing specialty of addiction medicine. The American Board of Psychiatry and Neurology now offers a subspecialty board certification in addiction medicine for physicians who are already board certified in psychiatry. In addition, the American Society of Addiction Medicine offers a certification of added qualification in addiction medicine for psychiatrists who are already board certified. Certification ensures that physicians who practice addiction medicine share a baseline understanding of the knowledge and skills on which their specialty is based.

Responsibility for AOD abuse treatment does not lie in the hands of physicians alone. It is increasingly shared among nurses, nurse practitioners, physicians' assistants, addiction counselors, social workers, nurses' aides, and other providers, as well as by managed care organizations. For this reason, the movement toward certification and inservice training programs for health providers should be expanded. A multidisciplinary, coordinated approach is essential. To ensure high-quality care, providers will need to establish referral networks and linkages among various treatment modalities.

Finally, unprecedented advances in the basic and behavioral sciences hold promise for the future of substance use disorder treatment. Chief among these are the recent growth in knowledge concerning how AODs affect brain cells and an appreciation of neurocognitive functioning. Some of this knowledge has direct application to AOD abuse treatment, particularly to detoxification.