Detox is the process that allows the body to rid itself of the substances to which it has developed dependence, often after periods of chronic use. The process of withdrawing from drugs and alcohol can be physically uncomfortable and emotionally turbulent. Fortunately, medications can be used to manage certain withdrawal symptoms to facilitate this early and important step toward long-term recovery.
Exactly which medication(s) will be used as part of a medical detox protocol depends largely on what substances are being used. Throughout the detox process, many people will experience some form of withdrawal from the substances they’ve been using and, in some cases, the withdrawal syndrome may be quite severe. The types of symptoms experienced will vary in association to the different substances once being used.
In some cases, withdrawal may be managed supportively—with comfortable surroundings, staff support, and over-the-counter medications for minor symptomatic relief. For instance, gastrointestinal upset and diarrhea can be managed with adjunctive, over-the-counter therapies like Maalox and Pepto-Bismol, while headaches and aches and pains throughout the body can be managed with OTC analgesics like acetaminophen and ibuprofen. With more significantly troublesome or severe symptoms such as depression or seizure activity, appropriate prescription medications may be indicated.
Medications for Heroin and Opioid Painkiller Detox
Medical detox treatment approaches for opioid dependence will be similar for both heroin and prescription opioid painkillers. Commonly utilized, FDA-approved treatment medications include buprenorphine and methadone. The California Society of Addiction Medicine reports success rates as high as 90 percent for methadone, with buprenorphine being similarly effective.
Treatment with either drug requires daily dosing. A buprenorphine treatment regimen may offer somewhat more freedom than methadone, since specially certified clinicians are able to prescribe the medication from their clinic or office. Methadone programs are relatively more strict in their implementation and require patients to show up to treatment daily for their dose. Patients may also need to submit for routine urine screening and participate in group therapy activities in order to stay in the treatment program.
Since opioid drugs are so addictive, and their associated withdrawal syndrome so unpleasant, they are relatively difficult to quit cold turkey or detox from within a short time frame like some other substances. Both methadone and buprenorphine help stabilize people in early recovery from heroin and opioid painkiller misuse and are then often used to slowly wean individuals off the treatment medications themselves. This slow weaning process helps to stave off cravings and eliminate the majority of withdrawal symptoms that people would feel without medical intervention. In some cases, people are maintained on a replacement treatment regimen for at least a year.
During detox from any kind of opioid, people may experience a lot of discomfort, including muscle and bone aches as well as gastrointestinal disturbances, both of which can be treated with over-the-counter medications in many cases.
Clonidine, an alpha-2 adrenergic agonist medication, has been used off-label to manage certain symptoms of opioid withdrawal for years. Though certain symptoms like insomnia and cravings may be less affected by this medication than opioid agonist therapy, many common opioid withdrawal symptoms such as excessive eye watering, runny nose, sweating, fast heart rate, and some gastrointestinal symptoms are often significantly reduced with clonidine treatment
Chronic opioid use is commonly associated with constipation. As a result of coming off them and gradually lowering the dose of treatment drugs, diarrhea is often the result. Over-the-counter anti-diarrheal medications are the go-to solution for this in many cases along with adequate hydration and appropriate dietary changes. Other adjunctive medications that may be used to manage some of the troublesome symptoms of opioid withdrawal include trazodone or certain antihistamines (e.g., diphenhydramine, hydroxyzine) for insomnia and, as mentioned, NSAIDs or acetaminophen for any muscle/bone/joint aches and pains.
Medications Used for Detox from Cocaine and Other Stimulants
Unlike medical detox for opioid dependence, there are no FDA-approved replacement medications for cocaine and amphetamines (including methamphetamine). Stimulant withdrawal rarely presents any immediate danger to the individual, nor is it often associated with markedly unpleasant symptoms. The detox procedure will therefore often be relatively less intense than that for substances like opioids and alcohol, and efforts will often emphasize sleep, nutrition, and conservative symptomatic management when needed to keep a patient as comfortable as possible in early recovery. Some commonly experienced stimulant withdrawal effects include:
- Sleep disturbances (insomnia or hypersomnia).
- Concentration problems.
- Slowed thought processes and motor activity.
- Intense cravings.
- Extreme paranoia and anxiety.
In addition, people may experience increased appetite, cold chills, and muscle weakness. Different adjunctive treatment medications can be used to manage these symptoms of withdrawal. Though rarer, in more serious cases of stimulant withdrawal, wherein significant dysphoria, depression, and potential suicidality arise, antidepressants and vigilant clinical management may be used to manage symptoms and keep the person safe.
Medications Used During Withdrawal from Prescription Benzodiazepines
Benzodiazepine abuse can be a challenge to treat since those who misuse these drugs are often suffering from an underlying, anxiety-based mental health issue that will require additional management once the abused anxiolytic medication is discontinued. Perhaps surprisingly, this class of drugs may actually be more likely to be abused when prescribed to certain individuals with existing mental health issues. In a study of 203 people being treated for co-occurring substance use and serious mental health disorders, 15 percent who were prescribed benzos developed an addiction to them in contrast to only 6 percent of those who weren’t prescribed these drugs.
Benzodiazepine detox itself also presents challenges to clinicians as relatively severe symptoms such as seizures and agitation may arise in the newly-abstinent, physically dependent individual.
People who have developed significant physiological dependence on benzodiazepines benefit from following a tapered dosing schedule in order to come off them safely and limit the risk of severe, unpleasant withdrawal.
A slow tapering schedule might take place over the course of several weeks, if not months. Some people may experience immediate onset of withdrawal, but in some cases, withdrawal symptoms don’t peak until several days to weeks after tapering has begun.
Tapering may take place utilizing the specific benzodiazepine that was already being taken or, in some cases, might require first switching to another agent—typically a longer-acting benzodiazepine than was being used.
Irritability, anxiety, and insomnia may be far more difficult to treat since the very drugs that were being used to manage these and similar issues are those that the individual is dependent on. In most cases, various cognitive behavioral therapeutic approaches will be used to complement any pharmacologic protocol (e.g., a sedative taper) that is already being used.
Medications for Detox from Hallucinogens, Club Drugs, and Synthetic Drugs
Hallucinogens like LSD, club drugs like MDMA, and synthetic cannabinoids and cathinones continue to make their way around the country. Classical hallucinogens are not associated with any distinct withdrawal syndrome; however, in rare cases, residual symptoms (e.g., persistent perceptual changes, anxiety, some mild cognitive impairments) arising after a period of active intoxication may require supportive attention from the detox team to make the recovering individual feel safe and comfortable. Pharmacologic intervention may be considered if symptoms prove significantly distressing.
MDMA withdrawal may manifest similarly to the crash experienced during withdrawal from other psychostimulant drugs such as methamphetamine. The features of withdrawal may include concentration problems, fatigue, anxiety, and mild depression, though they rarely require specific medical intervention prior to resolution.
Among synthetic drugs, like bath salts and Spice, some more complex clinical presentations may arise.
Though information on these relatively new drugs is not exhaustive, by any means, there are case reports of severe associated withdrawal events, including violent behavior and persistent amnesia.
In most cases, these side effects resolve following the initial detox period. However, given the potential need for more emergent medical attention during the acute intoxication period for these drugs, detoxification efforts should provide thorough supervision, frequent progress evaluations, and allow for the escalation to a more acute care setting, if required.
Medications for Marijuana Withdrawal
Despite previous beliefs, many in the addiction field have described a distinct marijuana withdrawal syndrome seen to arise in a significant portion of heavy users who suddenly quit. In 2013, findings from SAMHSA’s National Survey on Drug Use and Health indicated that 845,000 individuals received some form of substance use treatment for marijuana use. Some people detoxing from marijuana find themselves feeling depressed, anxious, irritable, and tired due to lack of restful sleep during withdrawal. The marijuana withdrawal syndrome rarely requires prescription pharmacologic intervention, though screening for and adequate medical treatment of significant anxiety, depression, and suicidal ideation is recommended.
Medications for Alcohol Detox
People who detox from alcohol or other depressants may experience symptoms that range from mildly unpleasant to potentially dangerous. Some of these include:
- Elevated heart rate and blood pressure.
- Nausea and vomiting.
- Loss of appetite.
- Increased sensitivity to sensory stimuli and headaches.
- Sleep disturbances and nightmares.
- Concentration difficulties.
- Hallucinations and delusions.
- Generalized seizures.
More severe complications of acute alcohol withdrawal, such as delirium tremens, affect around 10 percent of people who withdraw from alcohol, per the National Institute on Alcohol Abuse and Alcoholism. Because of the risk for agitation, seizures, and other potentially severe symptoms, detox for alcohol withdrawal frequently involves round-the-clock monitoring and the use of sedative medications for seizure prophylaxis. Benzodiazepines are commonly the agent of choice to this end as they calm psychomotor agitation. Valium (diazepam) and Librium (chlordiazepoxide) are commonly administered to manage alcohol withdrawal during a medical detox.
When more than one substance of abuse is at play, withdrawal can be slightly more complex, but that shouldn’t deter anyone from seeking help. Individual withdrawal syndromes can be prioritized in terms of the risks they pose to a recovering polydrug user and managed accordingly.
In addition, support groups and therapy are great additions to any detox regimen. Detox on its own is no substitute for comprehensive addiction treatment and is typically followed by a longer period of structured substance use rehabilitation. With the help of professional staff members and medications, as needed, detox can be a manageable and life-changing experience.