An Introductory Look at Detox Medicine

What is detox? What meds are used? What about therapeutic modalities? What happens after discharge?

Introduction:

As a PMHNP you will have the opportunity to work in addiction medicine, should you desire. In this setting you are likely to encounter patients in various stages of detoxification. Treating detox patients requires a comprehensive understanding of the detox process, as well as the physical and psychological symptoms associated with withdrawal. In this post, we will provide you with essential information on treating detox patients, including tips for assessing and managing withdrawal symptoms, pharmacological interventions, relevant therapeutic modalities and approaches to promoting long-term recovery.

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DISCLAIMER

The content provided in this Substack post is for entertainment and informational purposes only and is not intended to serve as medical advice. The views and opinions expressed herein are those of the writer and should not be taken as definitive or authoritative. Readers should not rely solely on the information provided in this post to make decisions about patient care. Instead, use this content as a starting point for further research and consult a qualified healthcare professional before making any changes to treatment or medication regimens.

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Part I: Understanding the Detox Process

A. Definition of detoxification

Detoxification, or detox, is the process of removing toxic substances from the body. In the context of addiction medicine, detox refers to the process of safely withdrawing from alcohol or drugs. The goal of detox is to manage the physical and psychological symptoms of withdrawal, prevent complications, and prepare the patient for ongoing treatment.

B. Stages of detoxification

Evaluation and assessment: This stage involves a comprehensive evaluation of the patient's substance use history, medical history, and any co-occurring mental health disorders. The patient's vital signs and withdrawal symptoms are closely monitored, and a evidence based detox plan is created in accordance with the patient's individual needs & preferences.

Stabilization: The stabilization stage involves managing the patient's withdrawal symptoms and addressing any medical or mental health complications that may arise during detox. Medications and other treatments may be used to manage symptoms such as nausea, vomiting, seizures, and anxiety. The goal of this stage is to help the patient achieve physical and emotional stability and prepare them for the next stage of treatment.

Medical detoxification: This stage involves the actual process of removing the substance from the patient's body. This may involve tapering off the substance gradually or using medications to manage withdrawal symptoms. The patient's vital signs and symptoms are closely monitored, and medical interventions are provided as needed to ensure their safety and comfort.

Rehabilitation: Once the detox process is complete, the patient is ready to begin the process of rehabilitation. This may involve inpatient or outpatient treatment, individual and group therapy, and ongoing support and care to help the patient maintain their sobriety and prevent relapse. The rehabilitation stage is essential to help the patient address the underlying issues that led to their substance use and develop the skills and coping strategies they need to live a healthy and fulfilling life in recovery.

Part II: Assessing and Managing Withdrawal Symptoms

A. Physical withdrawal symptoms

Opioid withdrawal symptoms:

• Opioid withdrawal symptoms can vary in severity depending on the individual's level of dependence and the specific opioid used. Mild symptoms may include anxiety, agitation, sweating, yawning, and muscle aches. As the withdrawal progresses, individuals may experience nausea, vomiting, diarrhea, abdominal cramping, and dilated pupils. Typically, opioid withdrawal is not considered a medical emergency, however in some instances (usually due to medical comorbidity) it is.

• The duration of opiate withdrawal can also vary, with symptoms typically starting within 12 hours of last use and peaking between 48 to 72 hours. Symptoms can last up to one week or longer, with the duration of withdrawal depending on the individual's level of dependence and the specific opioid used.

Alcohol withdrawal symptoms:

• Cause: Alcohol use potentiates GABA & inhibits glutamate. After prolonged repeat exposure, tolerance develops & neural adaptations occur. What this looks like is a downregulation of GABA & upregulation of Glutamate. Overtime this change is imperceptible, but it becomes quite apparent in the absence of alcohol use.

  • On a somewhat related note, a blood alcohol level is not indicative of either intoxication or withdrawal. But must be considered in the context of the entire clinical picture. If you have any questions about this leave a comment at the end of this post.

• Alcohol withdrawal symptoms typically begin within 6-12 hours after the last drink and can last up to several weeks. The first stage of alcohol withdrawal is characterized by mild to moderate symptoms, including anxiety, tremors, sweating, nausea, and insomnia. This stage typically peaks within 24-72 hours after the last drink and may also include hallucinations.

• Seizures may occur & usually do so within 12-48 hours after the last drink. Seizures can range from mild to severe, and typically subside within a few minutes. However, in rare cases, seizures may occur repeatedly and require medical attention.

• The most serious complication of alcohol withdrawal is delirium tremens (DTs) and it typically occurs 2-3 days after the last drink. DTs is characterized by confusion, hallucinations, fever, seizures, and high blood pressure, and can be life-threatening if not treated promptly. DTs require immediate medical attention and hospitalization.

Benzodiazepine withdrawal symptoms:

• Benzo withdrawal can range from mild to severe and can last for several weeks. The onset of withdrawal symptoms depends on the half-life of the benzodiazepine taken, with short-acting benzodiazepines causing earlier onset of symptoms. Withdrawal symptoms usually start within 24-48 hours of the last dose and can include anxiety, insomnia, tremors, and seizures. Delirium and hallucinations are rare but may occur in severe cases. As the withdrawal progresses, symptoms can become more severe and include agitation, confusion, and psychosis. It is important to taper the medication gradually under medical supervision to avoid severe withdrawal symptoms.

Stimulant withdrawal symptoms:

• Stimulant withdrawal symptoms can be categorized into two phases: the crash phase and the post-acute withdrawal phase.

• During the crash phase, the individual may experience symptoms such as fatigue, increased appetite, insomnia or hypersomnia, vivid dreams or nightmares, and irritability. These symptoms can occur within hours to days after discontinuing the stimulant use.

• During the post-acute withdrawal phase, the individual may experience symptoms such as depression, anxiety, fatigue, and cognitive impairments such as difficulty concentrating or memory problems. These symptoms can last for weeks or months, and can sometimes be more prolonged in individuals who have used stimulants heavily or for an extended period of time.

  • it is important to assess for suicidal ideation during this phase!

It is important to note that withdrawal from certain stimulants, such as cocaine or methamphetamine, can also result in intense cravings and potential for relapse. In addition, abrupt discontinuation of certain stimulants, such as benzphetamine or phentermine, can lead to more severe withdrawal symptoms such as psychosis or seizures.

B. Psychological withdrawal symptoms

Psychological withdrawal symptoms can be just as challenging as physical symptoms for individuals detoxing from drugs or alcohol. Anxiety and depression are common psychological symptoms experienced during the withdrawal process. Anxiety may manifest as excessive worry or fear, and it can be accompanied by physical symptoms such as sweating, palpitations, and trembling. Depression may be characterized by feelings of sadness, hopelessness, and loss of interest in activities. It may also cause physical symptoms like fatigue, changes in appetite, and sleep disturbances.

Cravings and triggers are another psychological symptom that can make detoxification difficult. Cravings are intense urges to use drugs or alcohol and can be triggered by internal factors such as stress or external factors like people, places, or situations associated with past substance use. Cravings can cause strong emotional responses and can be difficult to manage, especially during the early stages of detoxification.

Sleep disturbances are another common psychological symptom of withdrawal. Individuals may experience insomnia, difficulty falling asleep or staying asleep, or nightmares. Lack of sleep can worsen other withdrawal symptoms, such as anxiety and depression, making the detox process more challenging. It is not uncommon for individuals to utilize seroquel on a short term basis during detoxification due to it’s usefulness for sedation as well as anxiety.

Mood swings can be expected, and individuals may experience rapid changes in mood or emotional instability. Mood swings can be triggered by factors such as stress, lack of sleep, body aches, or other withdrawal symptoms. In the inpatient detox setting, mood swings are sometimes attributed to external factors such as dissatisfaction with the unit schedule or staff personalities. Sometimes individuals have co-occuring personality disorders that become more prominent during detoxification.

Overall, psychological withdrawal symptoms can be challenging to manage and may require a combination of therapies such as medication, counseling, and behavioral interventions to help individuals cope with the emotional and psychological challenges of the detox process.

Part III: Pharmacological Interventions for Detoxification

A. Medications for opioid detoxification

Methadone

-       Indications: Methadone is used for opioid detoxification and long-term maintenance treatment of opioid addiction. It works by binding to the same receptors in the brain that opioids bind to. Saturating opioid receptors leads to a reduction of withdrawal symptoms and cravings.

-       Contraindications: Methadone should not be used in individuals with severe respiratory depression, acute or severe bronchial asthma, paralytic ileus, or known hypersensitivity to methadone.

-       Things to watch for: Methadone can cause respiratory depression, so it's important to monitor patients closely for signs of sedation and respiratory distress. Methadone can also interact with other medications and cause QT prolongation, which can lead to arrhythmias.

-       Side effects: Common side effects of methadone include constipation, nausea, vomiting, dizziness, sedation, and sweating.

-       Additionally: Methadone is also utilized for pain management. In some states, APRNs are licensed to utilize it for pain management only. Because of this you may be unable to utilize it whatsoever. You should also familiarize yourself with federal guidelines regulating its use.

Methadone is a full opioid agonist that can be used for opioid detoxification and long-term treatment. Methadone is tightly regulated due to its potential for abuse and overdose. It is important to monitor for respiratory depression and overdose when using methadone, as it is more dangerous in overdose than other opioid agonists.

Buprenorphine

-       Indications: Buprenorphine is used for opioid detoxification and long-term maintenance treatment of opioid addiction. Similarly to methadone, it works by binding to the same receptors in the brain that opioids bind. However, it is a partial rather than full agonist, which decreases risk of overdose, but can also precipitate withdrawal.

-       Contraindications: Buprenorphine should not be used in individuals with severe respiratory depression, acute or severe bronchial asthma, paralytic ileus, or known hypersensitivity to buprenorphine.

-       Things to watch for: Buprenorphine can cause respiratory depression, so it's important to monitor patients closely for signs of sedation and respiratory distress. Buprenorphine can also interact with other medications and cause QT prolongation, which can lead to arrhythmias

-       Side effects: Common side effects of buprenorphine include constipation, nausea, vomiting, dizziness, sedation, and sweating.

Buprenorphine is a partial opioid agonist that can be used for opioid detoxification and long-term treatment. However, it can also precipitate withdrawal in patients who are physically dependent on opioids. Avoid this by ensuring that patients are sufficiently into withdrawal, before initiating buprenorphine. Clinically this is often times beyond the 24 hour mark, or when COWs score is greater than 11. However this can vary from opioid to opioid. Buprenorphine is safer than methadone in terms of overdose risk, but caution should be exercised when prescribing to patients who have a history of respiratory depression or who are taking other medications that can cause respiratory depression.

Naltrexone

-       Indications: Naltrexone is used after opioid detoxification for the prevention of relapse in individuals with opioid addiction. It works by blocking the effects of opioids in the brain, reducing cravings and preventing the pleasurable effects of opioids. You can think of it as effectively breaking the link between the stimulus and reward, thus it is quite good at breaking the chain of addiction.

-       Contraindications: Naltrexone should not be used in individuals with acute hepatitis or liver failure, or known hypersensitivity to naltrexone. It is also contraindicated in individuals with current opioid dependence.

-       Things to watch for: Naltrexone can cause hepatotoxicity, so it's important to monitor liver function tests during treatment. Naltrexone can also cause opioid withdrawal symptoms if taken too soon after stopping opioid use, so it's important to ensure that patients are fully detoxified before starting treatment.

-       Side effects: Common side effects of naltrexone include nausea, vomiting, diarrhea, abdominal pain, headache, and dizziness.

Naltrexone is a full opioid antagonist that can be used for long-term treatment of opioid dependence. It is not recommended for opioid detoxification because it can precipitate withdrawal symptoms in patients who are physically dependent on opioids. Naltrexone is generally well-tolerated, but it can cause liver damage in rare cases. Patients should be monitored for signs of liver damage while taking naltrexone.

It comes in both an oral formulation as well as a once monthly long acting injectable. While the LAI may be considered expensive, it is very effective & rather cheap compared to the costs of repeat hospitalization.

B. Medications for alcohol detoxification

Benzodiazepines are the preferred medications for alcohol detoxification due to their effectiveness in reducing the risk of seizures and delirium tremens.

Remember, when an individual has chronic exposure to alcohol GABA is downregulated and abrupt cessation leads to an imbalance in GABA to glutamate in the brain. Benzodiazepines work by binding to GABA-A receptors and enhancing the inhibitory effect of GABA in the brain. This works to reduce excitation & reduce associated risks of seizures or onset of Delirium Tremens. Diazepam, lorazepam, and chlordiazepoxide are commonly used benzodiazepines for alcohol detoxification.

The choice of benzodiazepine depends on the individual patient's characteristics, including age, liver function, and history of substance abuse. The duration of treatment is usually 3-7 days, and the dose is gradually tapered down to avoid withdrawal symptoms.

Contraindications for benzodiazepines include hypersensitivity, respiratory depression, and severe hepatic impairment. Patients with a history of substance abuse or dependence may also require close monitoring during benzodiazepine detoxification.

Naltrexone is not typically used for alcohol detoxification, but rather as a medication for alcohol use disorder (AUD) treatment.

It works by blocking the effects of endogenous opioids, which are believed to play a role in alcohol reinforcement. It is available in oral and injectable forms, with the injectable form having a longer duration of action.

Naltrexone should be used cautiously in patients with hepatic impairment & it is contraindicated in patients with opioid dependence as it can precipitate withdrawal symptoms. If opioid use is suspected, you can utilize a narcan challenge, which will result in a less severe form of precipitated w/d. Patients on naltrexone should be monitored for signs of hepatotoxicity and opioid withdrawal.

Gabapentin is an anticonvulsant medication that has been shown to be effective in reducing alcohol withdrawal symptoms, particularly in patients with a history of seizures or cognitive impairment.

It works by reducing neuronal excitability through its action on voltage-gated calcium channels. The recommended dose of gabapentin for alcohol withdrawal is typically between 900-3600 mg/day, divided into three doses. Research has also demonstrated that gabapentin reduces risk of relapse when continued after detoxification.

Gabapentin should be used with caution in patients with renal impairment, and it may cause sedation or dizziness. Patients on gabapentin should be monitored for signs of respiratory depression and cognitive impairment.

C. Medications for Benzodiazepine Detoxification