Detoxification means changing the resolution of a toxic state. Basically the brain has been poisoned and the manifestations of this are changes in behavior and changes in heightened body functions and physiology. Different drugs have very different withdrawal patterns, but there are some basic principles of medically managed detoxification. First we provide a calm environment and provide structure to the patient to reduce anxiety. This is done regardless of the drug class. In the case of opiates/opioids, alcohol, sedatives, and tranquilizers, we treat the patient using a pharmaceutical that is cross-tolerant with the drug from which the patient is detoxing.

Opiates/Opioids

For opiate/opioid detox we can use methadone or buprenorphine (brand names Subutex and Suboxone). Actually, any opiate/opioid could work effectively, but only methadone, buprenorphine, and Ultram (tramadol) are legal for doctors in the US to use for detox purposes. So if you’re a heroin addict and you go to a doctor and the doctor says, “Here’s a bottle of Vicodin (or Percocet or OxyContin) and I’m giving this to you so you can get off heroin,” this is illegal. It’s illegal for any physician to prescribe an opiate for detox other than Suboxone, Ultram, or methadone in a federally licensed methadone clinic. While buprenorphine and methadone are commonly used for opiate/ opioid detoxification, increasingly, buprenorphine is the opioid detox medication of choice. Buprenorphine has revolutionized opiate/opioid detoxification. Unlike methadone, buprenorphine can be prescribed for detox from the doctor’s office, provided the doctor has permission from the DeA to prescribe it. In the “old days” we used a range of medications that we found useful for opiate withdrawal off-label. Then we would also have to give patients a lot of other medications, such as Valium for anxiety, sleeping pills for insomnia, Advil for pain, and other drugs for nausea, diarrhea, and cramping. Buprenorphine has made the medically managed opiate/opioid detoxification process much simpler. Ever since buprenorphine came out in the early- to mid-2000s, we’ve used it to detox patients off opiates/opioids effectively. Even though buprenorphine is an opioid, its formulation uses a clever piece of trickery. It’s a partial opioid agonist, so it binds to the opiate receptors and quiets the brain down, quelling withdrawal symptoms without creating the same high as a full agonist like methadone would. Buprenorphine has really improved the detox process because it makes the withdrawal much easier without the potential complications of methadone, and without needing to put patients in the hospital and load them up on all kinds of sedatives. Buprenorphine is the active ingredient in two brand-name medications—Subutex and Suboxone—that can be used for opioid detoxification and opioid maintenance/substitution. Subutex contains only buprenorphine, whereas Suboxone contains buprenorphine and naloxone. Suboxone is far more frequently prescribed because it has a unique built-in safety feature—its formulation is designed to prevent misuse by those who may try to inject the medication. When Suboxone is injected, the naloxone (an inverse antagonist that reverses the effects ofI usually keep patients on Suboxone for about ten days as a detox medication, but every patient is different. Some patients have to wean off more slowly than others. Other patients might take it for a few weeks and some for a few months. There are also patients who take it for years and who may stay on it. In this way, Suboxone can be used as a detox medication to ease withdrawal symptoms and also as a maintenance or substitute medication.

Stimulants

Stimulant (mostly cocaine and methamphetamine) withdrawal is very different. even though stimulant withdrawal is one to two weeks long, those who go through it don’t experience a strong physiological upheaval like that which occurs in withdrawal from alcohol or narcotics. However, most people who stop using cocaine and methamphetamine do experience depression and a lot of cravings. As far as stimulant detox, good medications have not yet been developed for this purpose. with stimulant detox we can’t tell people who are doing crystal meth or coke to simply use “a little bit less” crystal meth every day to gradually wean off it. That doesn’t work too well, nor do we tell people who are using cocaine to use less of that every day until they are off it. In the detox protocol, we just stop the substance. The problem is we really don’t have any good cross-tolerant medications for the stimulants. Some people have experimented with things like Ritalin or Adderall, which are pharmaceutical stimulants. But they’re really not mainstream solutions at this point, so we focus on keeping the patient comfortable and help him or her manage the depression, anxiety, and cravings of withdrawal. Obviously, caffeine is a stimulant, though a mild one compared to crystal meth or cocaine. I love it when people tell me they’re clean from crystal meth but they’re drinking fifteen cups of coffee a day and eating energy bars, drinking energy drinks, and taking caffeine or other stay-awake pills. So we end up detoxing them from those things as well. While withdrawal from cocaine and crystal meth is insignificant physiologically, it can be very significant psychologically and psychiatrically. when patients are high they’re “wired,” but when they’re coming down they feel acutely depressed and miserable, can sleep for long periods of time, and often don’t want to get out of bed. People coming off cocaine or crystal meth binges tend to get suicidal. They may commit suicide after a speed or cocaine run because they are terribly depressed as a consequence of the dopamine and other neurotransmitters in their brains that have been totally altered. This blog post is an excerpt from The therapist’s Guide to Addiction Medicine – A Handbook for Addiction Counselors and Therapists – by Barry Solof, MD, FASAM; Published by Central Recovery Press (CRP).