Drug detoxification

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Drug detoxification (informally, detox) is variously construed or interpreted as a type of "medical" intervention or technique in regards to a physical dependence mediated by a drug; as well as the process and experience of a withdrawal syndrome or any of the treatments for acute drug overdose (toxidrome). The first definition however, in relation to substance dependence and its treatment is arguably a misnomer and even directly contradictory since withdrawal is neither contingent upon nor alleviated through biological excretion or clearance of the drug. In fact, excretion of a given drug from the body is one of the very processes that leads to withdrawal since the syndrome arises largely due to the cessation itself and the drug being absent from the body; especially the blood plasma, not from ‘leftover toxins’ or traces of the drug still being in the system.

Contents

Some addiction medicine practitioners use the term withdrawal management instead of detoxification. [1] [2]

A detoxification program for physical dependence does not necessarily address the precedents of addiction, social factors, psychological addiction, or the often-complex behavioral issues that intermingle with addiction. [3]

Process

The United States Department of Health and Human Services acknowledges three steps in a drug detoxification process: [4]

  1. Evaluation: Upon beginning drug detoxification, [5] a patient is first tested to see which specific substances are presently circulating in their bloodstream and the amount. Clinicians also evaluate the patient for potential co-occurring disorders, dual diagnosis, and mental/behavioral issues.
  2. Stabilization: In this stage, the patient is guided through the process of detoxification. This may be done with or without the use of medications but for the most part the former is more common. Also part of stabilization is explaining to the patient what to expect during treatment and the recovery process. Where appropriate, people close to the addict are brought in at this time to become involved and show support.
  3. Guiding Patient into Treatment: The last step of the detoxification process is to ready the patient for the actual recovery process. As drug detoxification only deals with the physical dependency and addiction to drugs, it does not address the psychological aspects of drug addiction. This stage entails obtaining agreement from the patient to complete the process by enrolling in a drug rehabilitation program.

Rapid detoxification

Richard B. Resnick MD was the first scientist to investigate the idea of accelerated detox under anesthesia. In 1977, [6] he published a paper detailing the first procedures using Naloxone and clonidine. Shortly afterward, physicians began discussing anesthesia to reduce pain during rapid detox. Norbert Loimer, MD, Ph.D. published a paper in the '80s outlining the success of opiate detoxification under general anesthesia. Resnick and Loimer's early research served as the foundation for all forms of detoxification under sedation procedures used today. While physicians' protocols significantly differ, they still adhere to the principles described in the early publications. [7] The combined use of clonidine and naltrexone was found to be a rapid, safe, and effective treatment for abrupt withdrawal from methadone, as detailed in a paper published in The American Journal of Psychiatry in 1986. [8]

Since then, numerous clinics around the world have implemented detoxification under sedation procedures to assist patients in overcoming opioid use disorder. These procedures involve the administration of anesthesia and other medications to facilitate rapid detoxification of the body, effectively reducing the painful and uncomfortable symptoms of withdrawal. While the effectiveness of rapid detox has been a subject of debate, it remains a popular treatment option for certain individuals grappling with opioid addiction. The pioneering efforts of Resnick and Loimer have paved the way for ongoing research and advancements in this field, ultimately aiding more individuals on their journey to recovery.

Etymology

The concept of "detoxification" comes from the discredited autotoxin [9] theory of George E. Pettey and others. David F. Musto says that "according to Pettey, opiates stimulated the production of toxins in the intestines, which had the physiological effect associated with withdrawal phenomena. [...] Therefore treatment would consist of purging the body of toxins and any lurking morphine that might remain to stimulate toxin production in the future." [10] [11]

Rapid detox controversy

Naltrexone therapy, which critics claim lacks long-term efficacy and can actually be detrimental to a patient's long-term recovery, has led to controversy. Additionally, there have been many questions raised about the ethics as well as safety of rapid detox following a number of deaths resulting from the procedure. [12] [13] [14]

Some researchers say that relapses to injection use of illicit opioids during or following repeated detoxification episodes carry the substantial potential for injury associated with uncontrolled drug use and include drug overdose, infections, and death. [15]

See also

Related Research Articles

<span class="mw-page-title-main">Methadone</span> Opioid medication

Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid used medically to treat chronic pain and opioid use disorder. Prescribed for daily use, the medicine relieves cravings and opioid withdrawal symptoms. Withdrawal management using methadone can be accomplished in less than a month, or it may be done gradually over a longer period of time, or simply maintained for the rest of the patient's life. While a single dose has a rapid effect, maximum effect can take up to five days of use. After long-term use, in people with normal liver function, effects last 8 to 36 hours. Methadone is usually taken by mouth and rarely by injection into a muscle or vein.

<span class="mw-page-title-main">Naloxone</span> Opioid receptor antagonist

Naloxone is an opioid antagonist: a medication used to reverse or reduce the effects of opioids. For example, it is used to restore breathing after an opioid overdose. It is also known as Narcan. Effects begin within two minutes when given intravenously, five minutes when injected into a muscle, and ten minutes as a nasal spray. Naloxone blocks the effects of opioids for 30 to 90 minutes.

<span class="mw-page-title-main">Hydromorphone</span> Opioid medication used for pain relief

Hydromorphone, also known as dihydromorphinone, and sold under the brand name Dilaudid among others, is a morphinan opioid used to treat moderate to severe pain. Typically, long-term use is only recommended for pain due to cancer. It may be used by mouth or by injection into a vein, muscle, or under the skin. Effects generally begin within half an hour and last for up to five hours. A 2016 Cochrane review found little difference in benefit between hydromorphone and other opioids for cancer pain.

<span class="mw-page-title-main">Drug rehabilitation</span> Processes of treatment for drug dependency

Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin, and amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and stop substance misuse to avoid the psychological, legal, financial, social, and medical consequences that can be caused.

<span class="mw-page-title-main">Opioid use disorder</span> Medical condition

Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Opioid withdrawal symptoms include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood. Addiction and dependence are important components of opioid use disorder.

<span class="mw-page-title-main">Buprenorphine</span> Opioid used to treat pain & opioid use disorder

Buprenorphine, sold under the brand name Subutex among others, is an opioid used to treat opioid use disorder, acute pain, and chronic pain. It can be used under the tongue (sublingual), in the cheek (buccal), by injection, as a skin patch (transdermal), or as an implant. For opioid use disorder, the patient must have moderate opioid withdrawal symptoms before buprenorphine can be administered under direct observation of a health-care provider.

<span class="mw-page-title-main">Naltrexone</span> Medication

Naltrexone, sold under the brand name Revia among others, is a medication primarily used to manage alcohol use or opioid use disorder by reducing cravings and feelings of euphoria associated with substance use disorder. It has also been found effective in the treatment of other addictions and may be used for them off-label. An opioid-dependent person should not receive naltrexone before detoxification. It is taken orally or by injection into a muscle. Effects begin within 30 minutes, though a decreased desire for opioids may take a few weeks to occur.

A methadone clinic is a medical facility where medications for opioid use disorder (MOUD) are dispensed-—historically and most commonly methadone, although buprenorphine is also increasingly prescribed. Medically assisted drug therapy treatment is indicated in patients who are opioid-dependent or have a history of opioid dependence. Methadone is a schedule II (USA) opioid analgesic, that is also prescribed for pain management. It is a long-acting opioid that can delay the opioid withdrawal symptoms that patients experience from taking short-acting opioids, like heroin, and allow time for withdrawal management. In the United States, by law, patients must receive methadone under the supervision of a physician, and dispensed through the Opioid Treatment Program (OTP) certified by the Substance Abuse and Mental Health Services Administration and registered with the Drug Enforcement Administration.

<span class="mw-page-title-main">Opioid antagonist</span> Receptor antagonist that acts on one or more of the opioid receptors

An opioid antagonist, or opioid receptor antagonist, is a receptor antagonist that acts on one or more of the opioid receptors.

<span class="mw-page-title-main">Lefetamine</span> Chemical compound

Lefetamine (Santenol) is a drug which is a stimulant and also an analgesic with effects comparable to codeine.

<span class="mw-page-title-main">Lofexidine</span> Medication used for opioid withdrawal

Lofexidine, sold under the brand name Lucemyra among others, is a medication historically used to treat high blood pressure; today, it is more commonly used to help with the physical symptoms of opioid withdrawal. It is taken by mouth. It is an α2A-adrenergic receptor agonist. It was approved for use by the Food and Drug Administration in the United States in 2018.

Treatment Improvement Protocols (TIPs) are a series of best-practice manuals for the treatment of substance use and other related disorders. The TIP series is published by the Substance Abuse and Mental Health Services Administration (SAMHSA), an operational division of the U.S. Department of Health and Human Services.

<span class="mw-page-title-main">Opioid overdose</span> Toxicity due to excessive consumption of opioids

An opioid overdose is toxicity due to excessive consumption of opioids, such as morphine, codeine, heroin, fentanyl, tramadol, and methadone. This preventable pathology can be fatal if it leads to respiratory depression, a lethal condition that can cause hypoxia from slow and shallow breathing. Other symptoms include small pupils and unconsciousness; however, its onset can depend on the method of ingestion, the dosage and individual risk factors. Although there were over 110,000 deaths in 2017 due to opioids, individuals who survived also faced adverse complications, including permanent brain damage.

<span class="mw-page-title-main">Mark S. Gold</span>

Mark S. Gold is an American physician, professor, author, and researcher on the effects of opioids, cocaine, tobacco, and other drugs as well as food on the brain and behavior. He is married to Janice Finn Gold.

<span class="mw-page-title-main">Buprenorphine/naloxone</span> Opioid treatment

Buprenorphine/naloxone, sold under the brand name Suboxone among others, is a fixed-dose combination medication that includes buprenorphine and naloxone. It is used to treat opioid use disorder, and reduces the mortality of opioid use disorder by 50%. It relieves cravings to use and withdrawal symptoms. Buprenorphine/­naloxone is available for use in two different forms, under the tongue or in the cheek.

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<span class="mw-page-title-main">Opioid withdrawal</span> Withdrawal symptoms of opiates

Opioid withdrawal is a set of symptoms arising from the sudden cessation or reduction of opioids where previous usage has been heavy and prolonged. Signs and symptoms of withdrawal can include drug craving, anxiety, restless legs syndrome, nausea, vomiting, diarrhea, sweating, and an elevated heart rate. Opioid use triggers a rapid adaptation in cellular signaling pathways that, when reduced or stopped, can cause adverse physiological effects. All opioids, both recreational drugs and medications, when reduced or stopped, can lead to opioid withdrawal symptoms. When withdrawal symptoms are due to recreational opioid use, the term opioid use disorder is used, whereas when due to prescribed medications, the term prescription opioid use disorder is used. Opioid withdrawal can be managed by the use of opioid replacement therapy, while symptoms may be relieved by the use of medications such as lofexidine and clonidine.

<span class="mw-page-title-main">Andre Waismann</span> Israeli physician

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<span class="mw-page-title-main">Amorphinism</span> Medical condition

Amorphinism refers to the mental and physical symptoms arising when a morphine-addict is deprived of morphine. Morphine is a potent opioid agonist derived from poppy plants and was originally used as a painkiller before being abused for euphoric and relieving purposes. It gave rise to morphine dependence, which caused the development of morphine withdrawal symptoms when morphine is reduced or stopped.

References

  1. ↑ "SAMHSA updates opioid treatment program standards, including telehealth, and proposes removing "x" waivers to prescribe buprenorphine".
  2. ↑ "Adult Substance Use Withdrawal Management Services | Texas Health and Human Services".
  3. ↑ "Find Info on Medical Detox".
  4. ↑ U.S. Department of Health and Human Services (2006). Detoxification and Substance Abuse Treatment (Report). pp. 4–5.
  5. ↑ Thomas, Scot; MD. "Detox from Addiction – Importance of Drug and Alcohol Detox". American Addiction Centers. Retrieved 2020-09-23.
  6. ↑ Resnik, Richard (April 1977). "Naloxone-precipitated withdrawal: A method for rapid induction onto naltrexone". Clinical Pharmacology & Therapeutics. 21 (4): 409–413. doi:10.1002/cpt1977214409. PMID   849672. S2CID   23047907.
  7. ↑ Kleber, H D (November 1982). "Clonidine and naltrexone. A safe, effective, and rapid treatment of abrupt withdrawal from methadone therapy". Archives of General Psychiatry. 39 (11): 1327–1332. doi:10.1001/archpsyc.1982.04290110077013. PMID   7138234.
  8. ↑ Kleber, H D (July 1986). "The combined use of clonidine and naltrexone as a rapid, safe, and effective treatment of abrupt withdrawal from methadone". The American Journal of Psychiatry. 143 (7): 831–837. doi:10.1176/ajp.143.7.831. PMID   3717421.
  9. ↑ "Autotoxin Definition & Meaning". Dictionary.com. Retrieved 2022-05-13.
  10. ↑ Musto, David F. (1999). The American Disease: Origins of Narcotic Control (3rd ed.). Oxford University Press. p. 76. ISBN   0195125096.
  11. ↑ "Information About Alcohol Detoxification". Archived from the original on 2022-04-08. Retrieved 2016-11-20.
  12. ↑ Dyer, Clare (1998-01-17). "Addict died after rapid opiate detoxification". BMJ Publishing Group. Retrieved 2009-02-22.
  13. ↑ Leeder, Jessica; Donovan, Kevin (2006-03-10). "Coroner probes 'rapid detox' death: Addict succumbed during procedure. Second fatality linked to clinics". Toronto Star. Retrieved 2009-02-22.
  14. ↑ Hamilton, R. J., Olmedo, R. E., Shah, S., Hung, O. L., Howland, M. A., Perrone, J., Nelson, L. S., Lewin, N. L. and Hoffman, R. S. (2002), Complications of Ultrarapid Opioid Detoxification with Subcutaneous Naltrexone Pellets. Academic Emergency Medicine, 9: 63–68.
  15. ↑ Ling W, Amass L, Shoptaw S (Jun 2006) "A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network." PMID: 16042639
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