Detoxification prepares people to fully participate in an ongoing addiction recovery program. It is one component of a comprehensive treatment strategy.

DETOXIFICATION FACILITIES

Detoxification can be done on both an outpatient basis (mental health centers, addiction clinics or private clinics) or inpatient (hospital or residential treatment center). Inpatient detoxification allows the patient to be closely monitored, avoids exposure to the substance of abuse, and can speed up the process of detoxification. Outpatient detoxification has the advantage of being less disruptive to the patient's life and less expensive. The choice of setting depends on many factors such as the drug of abuse, amount and length of history of abuse, psychosocial issues, patient's age, and co-existing medical and/or psychiatric conditions among others.

While treatment centers often have their own detoxification facilities, others make arrangements for their patients with detoxification programs at nearby sites, including hospitals and clinics. There are licensed detoxification facilities in most areas of the United States .

Detoxification programs can be found by using the government's SAMHSA online treatment locator (findtreatment.samhsa.gov/facilitylocatordoc.htm). Click on detailed search in the left hand menu, fill in the city and state, and then check detoxification and the type of care desired (Outpatient, Partial hospitalization/Day treatment, Non-hospital residential or Hospital inpatient). Links to rapid detox programs can also be found at Recovery Resources Online.

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ALCOHOL DETOXIFICATION

Many patients experience mild to moderate symptoms during withdrawal and can undergo detoxification without medications if they receive supportive care and monitoring. Inpatient medical detoxification services are appropriate for alcoholics at risk for serious complications of withdrawal or those with co-existing medical conditions. These patients and those with previous alcohol withdrawal seizures, delirium tremens, or moderate to severe withdrawal symptoms should receive benzodiazepines to reduce the risk of adverse events. Other medications have also been used in the detoxification process including clonidine, an alpha-adrenergic agonist, and carbamazepine, an anticonvulsant used to prevent seizures or delirium.

More recently, outpatient detoxification has been shown to be as effective as inpatient treatment and less costly for people with less severe alcoholism. This requires daily follow-up and monitoring.

Outpatient detoxification is commonly performed by using a tranquilizer such as chlordiazepoxide 50 mg, oxazepam 15 to 30 mg, diazepam 10 mg, or lorazepam 2 mg every 6 hours for the first 24 hours. Additional medication can be provided as medically necessary and doses can be decreased as symptoms resolve. Supportive care for patients undergoing detoxification includes providing treatment for nutritional and electrolyte deficiencies, monitoring withdrawal severity and abstinence, and providing referrals to alcoholism recovery programs and self-help meetings.

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COCAINE DETOXIFICATION

While at the present time, no proven pharmacologic therapy for cocaine addiction exists, several kinds of pharmaceutical drugs have been used in the detoxification of cocaine. Withdrawal from chronic cocaine use produces anxiety, depression and intense cravings for the drug. Several types of pharmaceuticals address these issues in different ways.

Antidepressant drugs such as desipramine or a combination of phentermine and fenfluramine have been used to reduce cocaine withdrawal symptoms such as anxiety and depression. Benzodiazepines, tranquilizers such as Diazepam, have been used to reverse anxiety induced by cocaine withdrawal. Amantadine, an antidyskinetic used in Parkinson's Disease, may be an effective treatment for cocaine-dependent patients with severe cocaine withdrawal symptoms and may reduce cocaine craving. Bromocriptine, a drug that works on the brain's dopamine system, has been used to decrease the craving for cocaine during detoxification and to reduce mood disturbance.

Propanolol, a beta-blocker antihypertensive drug, may be useful for severe cocaine withdrawal symptoms, as it inhibits the effects of adrenaline, thereby calming the body's "fight or flight" response to stressful situations. Beta-blockers have been used clinically to treat general anxiety and anxiety associated with alcohol withdrawal. Propranolol's lessening of symptoms such as palpitations and sweating has helped to reduce cocaine craving associated with such symptoms . The use of beta-blockers in patients who have ingested cocaine, however, is not risk-free and can be associated with decreased coronary blood flow and increased coronary vascular resistance, predisposing patients to arrhythmia and triggering a hypertensive crisis. Delayed toxic effects are possible. Any use of beta-blockers in this setting requires careful monitoring and caution.

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OPIATE DETOXIFICATION

Rapid Detoxification: In this procedure drug withdrawal occurs while patients are asleep under general anesthesia. The patient is given intravenous injections of medications called opiate blockers which stop the action of narcotics and opiate drugs as well as injections of other medications that reduce the symptoms of withdrawal such as muscle relaxants or anti-nausea medications. This process results in rapid withdrawal from the physical effects of addiction. Through the use of opiate blockers such as naltrexone, naloxone, and nalmephine, physical detoxification is achieved within 4 to 8 hours. Rapid detox takes place in an intensive care unit of a hospital. Patients are usually discharged within 48 hours following recovery from anesthesia and assessment of their physical status.

Rapid detoxification helps reduce the distress of opiate withdrawal for people who are chemically dependent on narcotics such as heroin, Vicodin, Percocet, Demerol, Dilaudid, Darvocet, OxyContin, opium, morphine, codeine, oxycodone, hydrocodone, prescription painkillers, and all narcotic type drugs. It shortens the detoxification period and spares patients the pain and physical discomforts of withdrawal. It may be of great benefit to patients who suffer from severe withdrawal symptoms and who have failed repeatedly to complete conventional withdrawal programs . However, there are significant costs as well as risks associated with the use of general anesthesia. It is imperative that the procedure be performed by medical professionals who are highly trained in these procedures in a medical setting that is fully equipped to deal with any complications that may arise.

Stepped Rapid Detoxification: This alternative to rapid detoxification provides small doses of Narcan (Naloxone) subcutaneously and naltrexone orally every hour or so, together with reduced withdrawal management medications , mostly orally, as necessary. This approach using the slower oral and subcutaneous routes rid the body of the opiate more slowly than intravenous Rapid Detoxification . In addition the pacing can be controlled and responsive to any withdrawal symptoms that develop in the patient by having them quickly suck on Buprenorphine tablets under the tongue. There is less need for withdrawal management medications. The patient is alert and directly communicating with medical staff until the situation has been resolved. It is possible to be detoxified and stabilized on Naltrexone Maintenance Therapy with 2 to 4 small manageable bites. If someone tries to use any kind of opiate while they are on Naltrexone, they feel no effect because all of the receptors are completely blocked.

Ultra Rapid Detoxification: This procedure involves putting patients under general anesthesia and giving them a drug called Naltrexone which blocks all of their endorphin receptors. This accelerates the withdrawal process, pushing them into 100% detoxification within a 5-30 minute period. Although this is an extremely painful process it is tolerable under anesthesia. As with rapid detoxification, it is very costly and has significant medical risk.

Outpatient Detoxification
Outpatient medical detoxification is usually safe and effective for people who are more likely to have mild to moderate withdrawal symptoms. For instance, primary care-based opiate detoxification can be accomplished with a variety of medications such as buprenorphine-naloxone (BUP/NX) or clonidine alone or combined with naltrexone. Buprenex, newly approved by the FDA, can now be administered on an outpatient basis by physicians who receive a required eight-hour training. Using Buprenex, the detoxification can take between 7-14 days.

Methadone: The most common method of opiate detoxification is to use Methadone in an approved clinic and slowly taper the patient down from the usual dose to zero over a period of approximately 21 days. This process still entails an uncomfortable withdrawal period and patients often use drugs during the withdrawal period.

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