Medically supervised detoxification and rehabilitation therapies are respectively short, medium and long-term strategies for overcoming addiction. Detox units treat physical addiction by medically managing withdrawal to minimize discomfort and the temptation to relapse.
Rehab is a program of education and workshops to help people affected by a drug problem manage psychological addiction and prevent relapse. For patients with significant chemical dependency, detox is a prerequisite for rehab. Detoxification units advise most patients to pursue a course of rehabilitation after they overcome physical dependency.
Methadone is a well-known maintenance therapy for heroin addicts. This style of treatment aims to minimize harm due to criminality, cost and infection risk. Physical, and to an extent, psychological addiction is sated by substituting a safer, legal drug which bonds to the same receptors. This allows a patients life to be stabilized in preparation for eventual detox and rehab. This process can take months, years or in some cases decades.
The treatment of people with addictions is known as Addiction Medicine, and it has traditionally been the domain of psychiatrists, so many of the guidelines are published by psychiatric organisations. Do not be put off. Doctors do not consider people mentally ill simply because they use drugs (although long-term amphetamine, cocaine, LSD or cannabis use can have this effect).
The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) categorizes drug use as: experimental, recreational, abusive and dependent.
Experimental use is tentative and not part of an established lifestyle. Recreational use is more frequent use (usually of “soft” drugs such as alcohol or cannabis) in social activity. These patterns rarely require medical intervention to terminate, although you may have to ditch some of your acquaintances.
Drug abuse includes habitual moderate use and occasional excessive use, such as binge drinking. The DSM-IV criteria for drug abuse is two or more of the following:
- The drug is taken in larger amounts or over a longer period than is intended
- Persistent desire or unsuccessful attempts to cut down
- Devoting a great deal of time to obtaining the drug or recovering from its effects
- Giving up important social, occupational or recreational activities because of drug use
- Continuing use despite knowledge of having persistent or recurrent physical or psychological problems related to drug use
Drug dependence is abuse plus physical addiction, which is defined as tolerance (more drug for the same effect, or conversely less effect from the same dose), withdrawal (a characteristic physical syndrome) or using the drug to avoid withdrawal symptoms.
A drug abuse problem indicates a range of treatments, depending on the drug abused, psychological and social factors. Counselling is a common first step. Cognitive Behavioral Therapy (CBT) has been shown to be effective, especially in conjunction with other treatments.
Social changes ranging from breaking with a friend who deals to moving to a different state are often needed. Long term drug abuse problems tend to require a formal rehabilitation program.
For dependent users, medically supervised detoxification is strongly indicated. Relapse is common, but can be minimized by follow-up counselling or a formal rehabilitation program. Doctors strongly advise dependent opiate users to stabilize their life on maintenance therapy, make crucial changes and then either detox or gradually wean.
Detox: What does it involve?
Relieving withdrawal symptoms with medication is the essence of detox. The miserable experience of opiate withdrawal, for example, can be reduced to something akin to a bad cold. Apart from relieving suffering, this intervention allows people who cannot endure a cold turkey withdrawal to conquer chemical dependency.
Heroin withdrawal can start within twelve hours of the last hit. The intense craving is controlled with diminishing amounts of methadone (“methadone assisted detox”) or buprenorphine. Tremors can be suppressed with clonidine, and the cramps usually respond to quinine and hyoscine. Metoclopramide is often used to suppress vomiting.
Heroin constipates users, so it is no surprise that diarrhea figures prominently in the withdrawal syndrome. This is controlled with loperamide in severe cases. Withdrawal from heroin (a CNS depressant) induces a sense of anxiety, which can be substantially diminished by diazepam (another sedative). This leaves persistent yawning, sweating, a runny nose and watery eyes, an unpleasant but not insufferable experience.
Alcohol withdrawal can cause life threatening seizures, so medical supervision is required. Diazepam is commonly used to treat tremors and anxiety, and is sometimes supplemented with clonidine. Thiamine injections are commonly given to prevent the encephalopathy associated with alcoholism. Detox programs are also available for cannabis, cocaine and benzodiazepines.
Inpatient and outpatient detox
Inpatient detox usually involves a hospital stay of five to ten days. Detox units are supervised environments where drugs are not allowed. Chemical tests are often used to detect transgressions. Medication is dispensed at set times, and workshops and counselling sessions occur during the day. Videos and magazines are commonly employed to distract withdrawing patients.
Hint: Forming relationships in detox is not a good idea! Patients often feel very vulnerable and seek attachment, but the decision-making environment is less than ideal. Staffs warn this is a bad time to add another turbulent person to your life!
Outpatient detox involves an initial consultation with a doctor, who prescribes the appropriate medications, and often also with a community nurse. The patient then withdraws at home. More structured programs involve daily visits by a nurse, who administers medications and checks on the patient’s progress. Followup counselling is strongly advised. Home detox is more appropriate for people with good support at home, and is very difficult if the patient lives with someone who uses.
Rehabilitation is a prolonged process, with schemes ranging from two weeks to six months or longer. Typical rehab activities include CBT counselling, group therapy, life skills workshops and confidence building exercises. Most courses focus on strategies to prevent a lapse becoming a relapse.
Outpatient programs, which vary from weekend or night classes to daily seminars, are appropriate for more mature patients with relatively stable lives. People with severe, long-term problems are usually referred to residential rehab.
Coming out of rehab or detox, it is crucial to have a plan for avoiding relapse. Successful plans involve avoiding the places where drugs are used, the people who deal them and (sadly) those you used with. This can be a hard decision, more painful than the relatively benign detox experience. Other tactics include changing the route home from work to avoid a pub or beer billboard, or even moving to a new city.
Long-term follow-up can be beneficial, in the form of individual counselling or Alcoholics Anonymous and Narcotics Anonymous support groups.
Contacts: The most important thing is to contact your doctor. Like all medical centers, your personal information is strictly confidential, and you won’t get into trouble for talking to a doctor about detox programs.