McLean Hospital 115 Mill Street Belmont, MA 02478
Detoxification from alcohol and/or drugs is an important first step in recovery. However, it’s not only important to take that first step, but also to do it safely.
There are several types of medical detoxification (detox), including detox from alcohol, benzodiazepines, or opioids.
When someone requires alcohol detox, the patient’s alcohol intake is stopped fairly abruptly. In order to moderate the effects of this quick stoppage, we give them a medication that tempers less severe symptoms and helps prevent the more dangerous symptoms of withdrawal. The medications typically used for alcohol detox are all in the benzodiazepine family, including diazepam (Valium), chlordiazepoxide (Librium), lorazepam (Ativan), and oxazepam (Serax). Sometimes, detox for alcohol utilizes other classes of medications, such as anti-seizure medications and barbiturates.
Our detox program at McLean Hospital, starts with a 24-hour evaluation. During this time, we check the patient’s blood pressure, pulse, respiration, ability to walk and stand, and other factors to determine how much medication should be used at the outset. The dosage is then reduced significantly each day, and in most cases, by the end of four to five days, the patient has been detoxed from alcohol.
In order to detox from benzodiazepines, the general approach is to gradually reduce the patient’s intake of benzodiazepines. Detoxing from benzodiazepines is typically a much lengthier process than detoxing from alcohol, often taking place over the course of weeks or several months as an outpatient. Vital signs will be monitored throughout treatment, and non-benzodiazepine medications may be used to reduce withdrawal discomfort.
For opioid detox, the standard approach is to replace the illicit opioids a patient is using with safely prescribed opioid medications, such as buprenorphine or methadone. At McLean, we use buprenorphine. The evidence supports maintaining patients on these medications for extended periods to stabilize recovery. However, for patients who decline this or do not have access to medication maintenance, opioid detoxification can be accomplished over four to fourteen days, depending on the medication used.
I believe that safety, comfort, and effectiveness are the three most important reasons why detox should be performed in a medical setting.
In a medical detox setting, a patient gets 24-hour care. Nurses and doctors check vital signs, make sure that the patient’s blood alcohol level is coming down safely, evaluate liver function, and do whatever they can to make the patient feel as comfortable as possible. Nobody likes to experience pain, so I think that this focus on safety and comfort gives people a leg up on their journey to recovery. By getting through this first step without feeling terribly uncomfortable, it helps to develop a mindset in patients that they can stay substance-free, that there truly is recovery at the end of the road.
Unfortunately, the vast majority of people who need treatment either try to detox on their own or fail to seek treatment at all. I think that a lot of factors contribute to this situation.
In some cases, there is a lack of accessibility—sometimes real and sometimes perceived. For instance, there may not be enough accessible treatment options in the area where the potential patient lives or their insurance may not adequately cover their needs.
Another hurdle is that most programs require abstinence, and not everybody wants to do that right away. These people may choose to try detoxing by slowly reducing their usage.
Other reasons include not understanding the medical risks of stopping on their own, frustration after a failed attempt at detoxing, and the lack of desire to get clean.
The potential physical and psychological effects of benzodiazepine and alcohol withdrawal include shaky hands, sweating, mild to severe anxiety, nausea, vomiting, headaches, insomnia, and urges to drink or to take pills. Opioid withdrawal is similar but often also involves diarrhea, which can lead to dehydration as well as vomiting, chills, leg cramps, depression, watery eyes, runny nose, and a strong craving for opioids.
“I believe that safety, comfort, and effectiveness are the three most important reasons why detox should be performed in a medical setting.”
Severe cases of benzodiazepine and alcohol withdrawal may be life-threatening. Benzodiazepine withdrawal can lead to seizures, and severe cases of alcohol withdrawal can lead to seizures or delirium tremens (a life-threatening confusion state in which a person may experience hallucinations and distress).
We recommend that patients continue with some type of therapy after completing a detox program and continue medication maintenance for opioid use disorder. Opportunities for therapy include intensive outpatient treatment (partial hospital/day programs), residential treatment, group therapy, individual therapy, or self-help groups, such as Narcotics Anonymous or Alcoholics Anonymous.
Patients may also be offered medication-assisted treatment to help them maintain their sobriety. For alcohol use disorders, naltrexone can be administered via a pill or an injection, and other approved treatments include acamprosate, disulfiram, and topiramate. For opioid use disorder, monthly doses of injectable naltrexone, buprenorphine, or methadone will reduce cravings and promote abstinence from opioid use. All medication treatments should be regularly monitored for effectiveness by a prescriber or care team.
If you would like more information about our medical detox services, please contact our Alcohol and Drug Abuse Inpatient Program at 877.814.9119.
Nancy Merrill, PMHCNS, BC, is a psychiatric nurse and the program director of McLean’s Alcohol and Drug Abuse Inpatient Program.