TREATMENT AND CARE
Medical detoxification is a service offered by many residential treatment centers. To effectively provide such support, it often requires the services of a hospital setting, such as the University of Colorado Hospital. Often referred to simply as Detox, the process can actually be highly dangerous for some people. If you or a loved one are entering treatment, with the requirement of medical detox, it can be helpful to know some basic things about the experience.
Tolerance and Withdrawal
Detox is a necessary process to help people work through their substance withdrawal in a safe fashion. This is most visible for people struggling with alcoholism. Long-term alcohol consumption at high volumes tends to build tolerance. This gradual building actually leads to some changes in the brain. Because alcohol is a nervous system depressant, it tends to slow down the brain’s functions. Noticeable might be poor coordination, balance issues, slurred speech, and foggy memory.
Because of a neurological phenomenon called plasticity, the cells of the brain are actually able to mold and adapt to long-term pressures, such as chronic alcohol intake. Over time, the traits listed above (coordination, balance, etc) seem to lessen. The person’s brain has grown to accept the high-content of alcohol, and in some ways actually, require it.
As the brain adapts and changes to the presence of alcohol, it essentially reaches a new normal state, one with alcohol in the system. Taking away alcohol can make the nervous system become very uncomfortable and hyperactive. This is what we see in medical detox.
The CIWA Protocol for Alcohol Detox
The most important goal of the nursing and physician team during alcohol detox is to help a person’s nervous system settle down safely. For some people, their system is so out of balance that the removal of alcohol can result in a seizure. This happens when the activating transmitters in the brain are living unopposed. They were held in check by alcohol, but now the alcohol is gone.
It is possible for someone to die from an alcohol withdrawal seizure, but this is relatively rare. Experiencing a seizure, though, happens more frequently than one might guess. Medical detox works to prevent seizures with sedative medications. In order to determine which people should receive such medication, our nurses will check for multiple signs and symptoms of withdrawal every few hours.
The specific instrument we use is a CIWA scale, or Clinical Instrument Withdrawal Assessment. This involves working with the person to watch for the following 10 signs and symptoms:
- Nausea and Vomiting
- Physical Tremor
- Excessive Sweating
- Agitation and Restlessness
- Sensory Touch Issues
- Auditory Issues
- Visual Issues
- Confusion and Cloudiness
If a person going through the detox process has multiple of these symptoms present within their first 72 hours since stopping the consumption of alcohol, we will often give them sedative medication to calm the nervous system. It is important to acknowledge the 72-hour window, as it is still possible to experience a withdrawal seizure in that time period. After those 3 days, the risk for seizures and harmful outcomes decreases.
In contrast to alcohol detox, it is not possible to die from opioid detox. Opioid refers to both heroin and opioid painkillers such as oxycodone. The withdrawal symptoms in this condition tend to feel quite miserable, including such issues as:
- Abdominal Cramping
- Nausea and Vomiting
- Excessive Sweating
- Hot and Cold Flashes
- Physical restlessness and Agitation
- Sensitivity to Light and Sounds
Many of these symptoms are strongly connected to the gastrointestinal tract because opioids tend to suppress that bodily system over time. When the person discontinues the opioid use, the GI system essentially rebounds, leading to some of the above symptoms.
There have been some medical cases of people experiencing severe blood pressure elevation during the detox process from opioids. This may be dangerous for people with a history of stroke or cardiovascular disease.
Just as the alcohol detox process involves our nurses administering the CIWA scale, we use a scale called COWS, or Clinical Opiate Withdrawal Scale, to rate the symptoms of opioid withdrawal. For some people, we will link the scores of the COWS scale with a specialized medication to alleviate opioid withdrawal – Buprenorphine. This medication is called a partial opioid and is often used for relapse prevention and maintenance therapy. It can be used briefly to help with the opioid detox process to lessen some of the symptoms.
We will also offer people some blood pressure medications to help alleviate sweating and restlessness. Clonidine is a centrally-acting blood pressure med which can be useful for some people. Once again, the goal of medical detox for people experiencing opioid withdrawal is comfort and treatment retention, somewhat of a different approach than that of alcohol withdrawal, which is more based on safety.
We have many people enter treatment to recover from cocaine or amphetamines. Because both of these drugs of abuse are nervous system stimulants, the detox process often looks like the opposite – fatigue, hunger, and depression.
The detox process for these addictions also is not dangerous to the body. There can sometimes be one complicating factor, though. It is possible for someone to become highly psychotic and disorganized through stimulant abuse. When this happens, we will sometimes provide advanced antipsychotic medication to help the person’s dopamine levels equalize. Interestingly, both cocaine and amphetamine drugs act directly on dopamine, hence the elevated levels can be so profound that the person can appear quite delusional and paranoid.
We do not use any dedicated nursing scales to track the detox progression from stimulants. Instead, we will watch for the person to become more active and start to engage in the whole treatment program. When this happens, the person will often be able to move to the next phase of the continuum of treatment.
We have some people who develop tolerance and withdrawal to benzodiazepine medications. These pills include such examples as Xanax, Klonopin or Valium. This detox process is actually quite similar to that of alcohol withdrawal, as the drugs act on the same central system as alcohol. This also means that a person can experience a seizure or delirium when trying to quit the drugs.
We will use the same CIWA scale to appraise benzo withdrawal in our detox unit. Sometimes, we will treat the withdrawal symptoms with barbiturate meds, instead of benzos, the meds commonly used for alcohol withdrawal. Benzodiazepine administration, for someone addicted to these very drugs, creates a dilemma for helping the person transition and fully detox to a clean state. Another way of saying this is that we would avoid giving someone addicted to benzos their “drug of choice,” i.e. benzodiazepines. We turn to a barbiturate instead.
For people who heavily use marijuana, they may experience some withdrawal symptoms when quitting and entering treatment. The detox from marijuana also tends to be the opposite of the core cannabis effects. A person may experience decreased appetite, insomnia, or increased blood pressure during detox.
There are not dedicated medications to treat cannabis withdrawal, just as with stimulant withdrawal. Instead, we would offer people some supportive meds around symptoms until the withdrawal subsides. We primarily work to encourage treatment engagement and retention towards overall substance recovery.
The detox process from nicotine and tobacco is also not life-threatening but can be highly agitating for many people. They will experience cravings, loss of energy, restlessness, and irritability. The most effective medications to help with the nicotine detox process are also meds used to help people make an overall attempt at quitting tobacco – nicotine replacement products.
Examples of nicotine replacement include patches, gum, or lozenges. These are quantified mechanisms which deliver nicotine to the body, and also are available with different dose ranges. Over time, a person can gradually decrease the potency of a nicotine patch or decrease the dosage of nicotine gum. This helps a person gradually wean off tobacco and make a full attempt at quitting.
Clinically qualified facilities will often work with people detoxing from multiple substances at the same time. For instance, we will often see people who have developed an addiction to heroin and methamphetamine. Another example is someone experiencing both alcohol and nicotine withdrawal.
Fortunately, most of the medical detox efforts and protocols do not interfere with each other. Buprenorphine medication can be effectively used for opioid detox at the same time as someone experiencing alcohol withdrawal and requiring benzodiazepines. For complex people such as these, it is of utmost importance that they receive structured medical detoxification from a qualified clinical treatment center. They are often trying to heal from numerous problems at the same time and really benefit from a safe place to make those changes.
Read more CeDAR Education Articles about Treatment and Care.