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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.
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 symptom 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.
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.
IN THE MATHEMATICS OF SUBSTANCE ABUSE, MOTIVATION>>>ADDICTION.
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.
For thousands of years, the Chinese have used acupuncture as a technique to relieve pain and maintain general health and emotional balance. In the traditional theory, there were roads of energy flows called meridians that coursed through the body; manipulation of these flows had therapeutic effects.
In western medicine, we do not recognize such energy flows but there is no question that acupuncture works. How does it work?
In pain physiology, there is a “GATING” phenomenon where the activity from stimulation of regular sensory nerves can reduce pain. It is as if there is a gate and only a certain amount of impulses can get through that gate in any period of time. Therefore, the more non-pain impulses get through, the fewer pain impulses can get through. This minimizes the number of pain impulses that reach the brain and we are less aware of the pain. It is why we rub our arms or legs after we get banged or injured; it produces mild pain relief. Nerve connections in the spine are partly responsible for this but release of endorphins in the spinal cord and brain play a significant role.
TENS machines (Trans-cutaneous Electrical Nerve Stimulation) have a well established role in pain treatment; they take advantage of this process. However, their effects are slightly different from those of acupuncture. When the acupuncturist places a needle, he twirls it a bit producing an electrical impulse. Usually he twirls it only a few times each second. Hertz is the way we measure the frequency of electrical impulses and acupuncture stimulation is usually is about 2-4 hertz (impulses per second). TENS machines usually stimulate at 100-150 hertz.
As it turns out, the lower hertz preferentially leads to release of certain types of endorphins (B-endorphin and enkephalin) while the higher stimulation produces a different type of endorphin called dynorphin. We would want to stimulate all the endorphins to get the most pain relief.
We can set certain TENS machines to a low hertz and we get an effect similar to acupuncture. It is not necessary to use needles; there are self-adhesive electrical pads which conduct the electrical impulse. These pads can be attached to specific acupuncture points in the body and hands; these points have been used for thousands of years. This process may be preferable to traditional acupuncture because we avoid the difficulties of placing, cleaning and disposing of needles. However, what is most important is that is makes it easy to have repeated treatments because the patient can place the pad himself.
A lot of people think of acupuncture as a procedure that you have just a few times. However, acupuncture should be thought of a medication which wears off after a period of time. Initially, in order to get a maximal effect, the treatment needs to be repeated 3-4 times a day. After a while, 1-2 treatments daily maintain that effect.
It seems that our periods of maximal pain occur in the early morning or late at night. Therefore, when one is most in need of treatment, it becomes impossible to see the acupuncturist soon enough. With this machine, a treatment can be done anytime.
Evidence has shown that alternating between high and low hertz will maximize the therapeutic effects. Pain can be relieved this way. I have found hat 2/3 or more of my patients get relief for periods ranging from 6 to 18 hours.
Also, severe opioid withdrawal syndromes can be relieved. In a study done in a western style detox unit, half the patients were given the acupuncture. All patients were allowed to use as much Suboxone as they wanted. Those receiving the treatment used less than 10% of the Suboxone that the control group did. Their vital signs normalized in 4 days versus 8 days in those patients who did not receive the treatment.
The machine that was used had a special setting where the rate of stimulation changed every three seconds. It switched from 2 Hertz to 100 Hertz and back. It is unclear whether machines that do not automatically make this switch can produce the same results. The treatments lasted for thirty minutes. There had some prior findings that acupuncture stimulation maximized after thirty minutes; using for longer periods could reduce the relief obtained.
It is also possible that the longer term use of the machine may reduce drug cravings with some studies showing a lower incidence of relapse. The benefit here is less marked.
One or two trial treatment can be done in the office. If it works, patients can consider getting their own machine.
The people who will most benefit are those that are undergoing acute withdrawal or those in acute pain or a combination thereof. The benefit for those who have a more chronic process is unclear.
I had mentioned in other articles that the intensity and duration of withdrawal is related to how quickly the receptors empty of drug. This is in turn related to how long the drug remains in the body. Heroin, which lasts a relatively short time in the body, has a more intense withdrawal syndrome. However, the equivalent amount of a longer lasting drug, such as methadone, has a less intense but more prolonged withdrawal syndrome. The Locus Coeruleus (LC) is the part of the brain responsible for withdrawal symptoms. It becomes over-active to a greater or lesser degree, depending on how quickly the drug leaves the receptors and the body. The idea behind accelerated withdrawal is to cause the receptors to empty faster than they normally would.
Opiate blockers are drugs that effectively kick out heroin or other drugs more quickly. They first bind the receptors and then essentially get stuck in the receptors. However, they do not activate them. These medications will cause a blockade by preventing any other drug in the body from activating the receptors. Essentially, you have a chemical wall between the bloodstream and the brain. The patients will go into withdrawal more quickly and more intensely.
The most commonly used antagonists are Narcan and Naltrexone. Nalmefene is a third agent. Narcan is administered through the vein and begins acting almost immediately. It has long been used in emergency rooms where it reverses the effects of drug overdose within minutes. It is also widely used in the community as a nasal spray. It causes significant withdrawal in these setting. However, the dose used these situations will not detoxify a person because they may not receive a dose sufficient to block all receptors. Also, Narcan disappears from the body very quickly after a single dose. Since there is still heroin (or other drugs) in the system after the Narcan is metabolized, compete detoxification never occurs
The other drug that is commonly used is Naltrexone. This is a pill that is taken once daily. Its’ onset of action is slower but it is effective all day. Its main use has been to prevent patient’s ongoing abuse of drugs since it will prevent the drugs from interacting with the receptors. Since they cannot get high or get pleasure from the drug, the patient will not have any desire to continue using the drug.
The use of Naltrexone to precipitate withdrawal has been established. A partial dose of Naltrexone is given on the first day. Then, progressively larger doses are given on successive days (most persons use a four to five day protocol). The patients are usually medicated with clonidine and sedatives. They may be given intravenous fluids. The intense withdrawal, usually worst on the first day, lasts several hours and then the patient goes home. They are uncomfortable but not as much as people might expect. By the end of the treatment, the patient is on a full blocking dose of Naltrexone with minimal withdrawal.
This procedure has some advantages over traditional withdrawal treatments. The worst of the withdrawal occurs while the patients are under medical observation. In addition, they are on a full blocking dose of Naltrexone 5 days after the start of the treatment. It is especially useful in treating withdrawal in persons who are coming off long-acting drugs, such as methadone and buprenorphine, where withdrawal may last 1-2 weeks. In persons undergoing traditional withdrawal, you need to wait at least one week before beginning Naltrexone. Disadvantages include increased costs and more involved medical care. In addition the patient is sent home between treatments and runs the risk of relapse.
Since the 90s, an even quicker procedure has been described known as Ultra Rapid Opioid Detoxification. This has been commonly referred to as a 24 hour detox. In this procedure, a full blocking dose of Narcan is given to the patient immediately and the drug level is maintained by the use of a constant intravenous infusion that lasts as little as three hours. In addition to the Narcan, Naltrexone (or Nalmefene which is a different type of blocker) is also given, at full blocking dosages, to maintain the antagonism after the Narcan is stopped. Because there is now a full blockade of receptors right at the onset, the LC becomes maximally active. The withdrawal syndrome would be too intense to tolerate; but patients are under general anesthesia throughout the administration of Narcan. Reportedly, the patient has relatively mild symptoms of withdrawal upon waking which resolve within one day.
People have trouble believing this can be accomplished so quickly. Yet, animal studies show that the over activity of the LC begins to resolve after 2-3 hours of full blockade. It is as if this area of the brain tires out from overexertion.
There are possible complications secondary to the invasiveness of the procedure as well as from anesthesia. Most of the established addiction experts are against this option. People have died. It is unclear that a greater percentage of patients achieve long-term abstinence. It is expensive and not covered by many insurance plans. I also have known some people to have the procedure three or four times.
It can be difficult to locate where this procedure is done but there is a place in Minnesota and another in Canada. It will cost over 10,000 dollars.
I do not mean to imply that I would never support the use of such procedures. For those patients who cannot or will not tolerate other procedures, this remains an option. However, the procedure’s most prominent proponents have been those who have a financial interest in continuing this treatment.
More recently, physicians in Mexico have offered ibogaine. This is a drug that comes from Africa and is both an opioid blocker and a hallucinogen. Patient apparently have a psychedelic experience and wake up detoxed.
There have been medical complications. Also, it is a schedule one agent and is illegal in this country. Established addiction medicine has been against this procedure. I am not sure I agree. It has been useful for many and has been less expensive than the "24 hr" detox. It apparently is less medically intense though it may last for a couple of days. I do not see what the basis for its outright rejection is. I believe it should be more closely studied. Although I will never recommend it, I will also not dissuade anyone from this either. Unfortunate, the only clinics that do this are outside the country
My major issue with the accelerated withdrawal techniques is that I do not feel there is a strong need for it. It is riskier, and more expensive than Suboxone protocols. Many opioid users manage to detox using conventional means but relapse at some later point. Relapse prevention, not detoxification, is where the challenge of treatment lies.
One of the most common misconceptions held about opioid maintenance is that its primary function is to help a person stop using drugs. While this is certainly a laudable goal, it should not be the primary focus. The primary goal should be to return the client to a normal, productive lifestyle with gainful employment and good relationships and the absence of psychiatric disease.
Suboxone and methadone are the two opioids we use for either detoxification or maintenance. I believe that weaning will be less damaging and intrusive n the long run. I offer weaning to almost all my patients. However, if these attempts fail, or if the patient is unwilling to risk the discomfort of withdrawal and possible relapse,, there is nothing wrong with long-term (perhaps even lifetime) maintenance.
The idea that maintenance could last a lifetime sits hard with many people both inside and outside the addiction world. Traditionally, treatments based on achieving abstinence have had high failure rates despite multiple, prolonged treatments. There are multiple physiological imbalance s that lead to severe cravings, inability to control behavior and symptoms of anxiety and depression and, we need to treat this as a disease. Other articles on this site detail the biological mechanisms behind this disease. I believe these abnormalities resolve to some degree in most and therefore they could attempt to wean. However, for a significant fraction, the abnormalities will not resolve. If these patients are forced to live opioid free, they will be depressed, anxious with significant drug cravings and at risk for relapse and over-dosage. For these patients, lifetime maintenance represents the best option. Unfortunately, there is no objective way to differentiate those who can live opioid free from those who cant. We have to be careful not to impose our own belief and value system on these patients; they must be allowed to determine what is the best course of treatment for themselves.
We are not simple substituting one drug for another. Suboxone and Methadone are different from most abused drugs. Most abused opiates are short acting drugs. This means they get into the body quickly and are metabolized quickly. When the drug is taken, there is a quick upsurge in the concentration of the drug in the brain. This results in euphoria and intoxication. After physical dependence develops, there are problems relating to the wearing off of the medication that occurs hours after the last dose. It leads to a mild degree of withdrawal and will adversely affect concentration, mood, and neurological function. The body will be under stress leading to a cascade of abnormal hormonal functions and immune suppression. The patient will obsess over drugs and resort to all sorts of aberrant behavior in order to obtain them. These behaviors not only disrupt the life of the addict and those around him, but affect us all through crime, motor vehicle accidents, other trauma, higher health costs and the need to maintain a variety of governmental interventions.
Almost everyone has been a passenger in a car. Travelling a a constant speed feels different that severe accelerations and braking. Similarly in the brain, when the drugs levels are constant, we feel no intoxication, euphoria or withdrawal. . Methadone or Suboxone have much more stable drug levels in the brain. Therefore, there is far less euphoria or intoxication (if any) and brain functions can stabilize. There is also none to minimal withdrawal. Many patients can and do lead more productive lives. Even those patients who continue to abuse other classes of drugs may still be in a better functional state with maintenance than they would have been without maintenance. Methadone and buprenorphine maintenance are designed to treat opiate dependency. They do not treat psychological dysfunction. They do not help other types of drug dependencies such as cocaine, sedative or alcohol.
The continued abuse of other drugs does not mean that treatment has failed. The patient may still appear out of control and is tempting to blame the methadone for the problem. However, Methadone and Buprenorphine are still usually part of the solution and not part of the problem. If the maintenance drug is withdrawn, the situation will get worse.
Methadone’s usefulness in maintenance was recognized 40 years ago. Initially, it was widely prescribed without restriction. Alas, if you put a lot of opiate into the community there will some misuse.. Diversion and overdose became problems when methadone was first being prescribed in the sixties Additionally, initiating methadone is tricky and can lead to overdose if not done correctly. In order to combat these problems,, clinics were developed to minimize the amount of drug on the street, standardize treatment protocols as well to engage the addict in a full range of services including closer monitoring and counseling. Unfortunately, there are lots of regulations. This makes being on methadone very cumbersome and patients, especially working patients, do not have adequate access to treatment.
Yet Methadone had been the most successful treatment in the latter 20th century. It minimized illegal behaviors, optimized pregnancy outcomes, prevented HIV infection and restored people to functionality. It is inexpensive (not counting the cost of a clinic)and able to stabilize opioid dependent patients even with very high tolerances.
It does not get into the bones or cause serious medical problems. It has other physiological actions that can stabilize certain psychiatric states and/or pain states. It is a good drug and a reasonable treatment option.
Methadone needs to be taken daily. Often, patients will come in daily at the beginning of treatment but may come in less often as time goes by. After three years, some may even have the option of monthly visits. Frequency of attendance at the clinic had been set by federal regulation. Regulations have become less stringent in the last few years but individual clinics may follow more restrictive protocols.
More than half of addicts have long term benefit. These are mothers, fathers, professionals. They go to the clinic weekly or monthly than get on with their lives. They want nothing to do with the drug scene and quickly disappear, Unfortunately, that leaves the rest who do not do well. They continue to misuse a variety of drugs . They hang around the clinic, buy and sell a variety of drugs and seem overly intoxicated, It is these who have become the face of the clinic and it becomes easy to disrespect the clinics, But we cant lose track of the fact that most do rather well.
In the last decade, Buprenorphine has become available. Doctors in their offices can give it provided the doctors have met certain requirements. The doctor is limited to 100 patients at any one time though highly qualified doctors can treat up to 275 patients at one time. Recently physician extenders such as physician assistants and nurse practitioners have also been able to obtain a license to prescribe suboxone which will increase availability of treatment. Pharmacies are able to fill prescriptions for the drug when written by those who have met the requirements.. Buprenorphine is taken as a sublingual (under the tongue) tablet. or film. It has two forms: Subutex, which is pure buprenorphine, and Subuxone, which has a combination of buprenorphine and Narcan. The Narcan is present to prevent patients from dissolving and injecting the medication. Such abuse has been a problem in other countries. The Narcan will not be absorbed from underneath the tongue.
Buprenorphine will not solve all problems. It is abused; all opiates are abused. However, it helps many people as well. I have found that about half of people do well long term; they stay free from all other suboxone It is safer to use than methadone; overdose is highly unlikely and intoxication is much less of a problem.
In sum, maintenance works for most addicts ans should be considered as a valid treatment option