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Most people who present to my office for detoxification do not have a good understanding of what this process entails.  They know that they get acutely ill when they come off drugs and alcohol.  What they do not really understand is how long this process takes.  In fact the detoxification process takes weeks to months.  It can be divided into a 3 periods: acute detoxification, early abstinence and recovery and maintenance.  I will cover opiate and alcohol in this article.  Please refer to the sections on sedatives and other drugs if you need to.


Acute detoxification- This process occurs in the first 2-5 days in alcohol detoxification and the first 3-10 days of opiate detoxification.  Essentially, this is the time you are ill and require intensive medical treatment.  In opiate withdrawal, buprenorphine may be dispensed and than other drugs are used for additional symtom relief.  In alcohol detox, Depakote, Lopressor and Librium are used. This is an intense process that requires close follow up.  One can expect to be seen two times over the first week. 


This is the process that most people think of when they think of detox.  It is an intense but relatively short-term process that a majority of persons can get through whether treated in an inpatient and out patient setting.  I believe that a shorter, more intense (within reason) process is more effective.  That is because people are motivated to do what is necessary early on in treatment.  However, as time goes by, that motivation is less strong.  A detox that last several weeks may outlast some critical period where the person is willing to tolerate moderate discomfort.  Many people who are still on addictive substances 1-2 weeks later, start to manipulate the provider into small extensions of the process.  They often relapse when the medications are stopped.  I limited the treatment to three days several years ago secondary to regulatory requirements as well as research findings.  The research demonstrated that three day opiate detoxifications were as effective as longer ones.   My experience confirmed that; more people completed detox when the protocol was shortened.


Early abstinence- This is a difficult time, especially when opiates are the drug of choice.  Just as tolerance develops differently in different parts of the brain, withdrawal occurs differently in different parts of the brain.  In opiate detox, the physical symptoms of withdrawal are moderated by one part of the brain (the locus coereleus) and resolve more quickly.  However, the structures involved in emotional control (limbic system) seem to take a longer time.  It is not unusual for depression, irritability, cravings and sleep disturbances to last a few months.  In alcohol detox, this period may last a few weeks.


Historically, this period has been ignored.  The patients find themselves at home knowing they feel bad.  Every one has told them that detox is over so why do they feel bad?  The doctors they are in contact with don’t know what’s going on.  At best, they are identified as having psychiatric problems.  Yet, these psychiatric symptoms don’t get better with the usual psychiatric medication.  After a while, the patient says “Fuckit, if I feel so bad, I might as well get high”.   This is a major reason why so many people relapse.


I always stress that the period is temporary.  I like to use a metaphor of a marathon; patients feeling mildly ill but feel bad for a long time.  It is difficult to treat but there are many non-addictive medications that are helpful.  Relaxation techniques, acupuncture and many other interventions work in select individuals.   Counseling and 12-step meetings help to bolster motivation.




Recovery  Recovery begins when the reasons a person wants to be drug free evolves.  A patient initially presents because their life has become painful.  They want to escape the negative consequences of their life.  At some point, their motivation must switch from wanting to avoid the negative consequences of abuse to wanting to live a life of recovery.  I define recovery as being content in the abstinent lifestyle.  It is not enough solely to be abstinent.  Negative feelings like anger, envy, sadness will eventually lead people back to their drugs.  Of course, everyone is upset from time to time but in recovery there is more time experiencing  positive emotions than negative ones.  The hallmark feeling of recovery is GRATITUDE.  After all, if we are happy than we are grateful for our lifestyle.  We can resist the diminishing drug cravings that will occur from time to time. 

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