The American Society of Addiction Medicine (ASAM), the leading national organization of addiction treatment professionals, clearly differentiates between what many sources refer to as “detox” and what they refer to as “withdrawal management.” Detox or detoxification is a natural bodily function that occurs as the body rids itself of waste materials and toxins. This function is primarily performed by the liver. Even a person who is actively using drugs will be undergoing detoxification, as it is an ongoing process. ASAM and international organizations such as the World Health Organization (WHO) prefer to use the term withdrawal management to refer to a direct form of intervention designed to assist an individual in withdrawal from drugs or alcohol. Many treatment facilities use the terms withdrawal management and medical detox interchangeably.
There is still some misconception between the notions of the development of physical dependence and addiction or a substance use disorder. Many people still consider these terms to be synonymous with one another; however, these are two different situations. Physical dependence consists of the development of both:
- Tolerance: This is a common situation that occurs when an individual takes some drug or medication. Typically, over time, the effects of the medication diminish unless the individual takes a higher dose of the medication. This is also true with drugs of abuse.
- The withdrawal or discontinuation syndrome: This is the situation that occurs as a result of a person’s system becoming habituated to the presence of a certain drug. The individual system adjusts its functioning so levels of hormones, neurotransmitters, etc., are regulated to account for the presence of the drug. When the levels of the drug in the person’s system decrease as a result of normal detoxification, the system is thrown out of balance. The person experiences a number of negative effects that can include nausea, vomiting, chills, and even hallucinations or seizures.
The development of physical dependence occurs over time as an individual regularly uses a drug or medication. It is generally accepted that the person will first develop tolerance and then withdrawal symptoms. People who chronically abuse certain types of drugs or alcohol may develop substance use disorders. By formal definition, a substance use disorder or addiction represents the nonmedicinal use of a substance that results in a number of negative ramifications for the person’s functioning, distress, issues with self-control, and other potentially dangerous or hazardous consequences.
Very often, individuals with substance use disorders have developed physical dependence as a result of their chronic substance use, and in many cases, they have not developed physical dependence on their drug of abuse.
Being diagnosed with the syndrome of physical dependence is neither necessary nor sufficient for an individual to be diagnosed with a substance use disorder, according to the diagnostic criteria in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5).
- When sources refer to withdrawal management, or medical detox, programs they are typically referring to physician-assisted withdrawal management programs. These programs are performed under the supervision of an addiction medicine physician and designed to assist people who develop physical dependence on drugs or alcohol to negotiate the withdrawal process safely and relatively free of distressing symptoms. Most often, physicians administer a number of different medications that assist in controlling withdrawal symptoms. They often administer these medications using a tapering strategy where at specific intervals, decreasing amounts of the medication are given to the patient in order to wean them off of the drug. They also administer additional medications and interventions to deal with cravings and other physical and emotional symptoms.
Physician-assisted withdrawal management programs are commonly performed in inpatient or residential programs, but they can also be administered on an outpatient basis for specific patients. The advantages to inpatient detox programs are that the physician can closely monitor the symptoms and progress of the patient and make adjustments to the specific program on the spot, whereas this may not be possible for an outpatient withdrawal management program. 1In addition, inpatient units isolate the patient from potentially toxic environments or situations that may trigger relapse.
Why Is Self-Detox Unsafe?
The vast majority of people with substance use disorders should not attempt to “self-detox.” This involves attempting to withdraw from substances of abuse without any medical supervision. Self-detox is also sometimes referred to as at-home detox.
This “cold-turkey approach” is fraught with a number of potential dangers. According to sources, such as The American Psychiatric Publishing Textbook of Substance Abuse Treatment, there are a number of situations where it can be potentially dangerous to engage in the practice of self-detoxing or a cold-turkey approach.
- The withdrawal process associated with an anxiolytic use disorder (addiction to benzodiazepines or barbiturates) and with an alcohol use disorder can have very serious and even potentially fatal consequences. Withdrawal from these substances may result in the development of periods of severe disorientation and psychosis (e.g., delirium tremens or DTs) that can lead to impaired judgment in an individual and the potential for harm from accidents.
In addition, even individuals with moderate anxiolytic use disorders or alcohol use disorders are at risk to develop seizures during the withdrawal process. These seizures can be potentially fatal. Because it is impossible to predict with complete accuracy who will and will not develop these potentially serious conditions during withdrawal from these substances, anyone who is attempting to discontinue their use of alcohol, benzodiazepines, or barbiturates should only do so under the supervision of a physician.
- Individuals who undergo withdrawal from opioid or narcotic drugs, such as morphine, heroin, OxyContin, Vicodin, etc., are not generally considered to be in danger of developing potentially fatal seizures; however, withdrawal from these drugs is often very severe and physically and emotionally draining. Individuals undergoing the withdrawal process from this class of drugs may develop issues with severe nausea, vomiting, stomach cramps, etc., that can lead to serious issues with dehydration.
In addition, individuals often become emotionally distraught and suffer issues with anxiety and depression during the withdrawal process. This leaves individuals vulnerable to relapse and overdose during the withdrawal process. Overdoses of narcotic drugs are potentially fatal. A physician-assisted detox program will often involve the use of opioid replacement medications that will significantly reduce the discomfort and dangers associated with the withdrawal process.
- Withdrawal from stimulant medications, such as cocaine, Ritalin, Adderall, methamphetamine, etc., can result in a number of significant physical and emotional issues. These can include issues with dehydration, anorexia, psychosis (hallucinations and delusions), and severe depression that may result in individuals becoming potentially suicidal. Those diagnosed with stimulant use disorders should always consult with a physician when attempting to discontinue use of these drugs.
- Clients who have histories of multiple types of drug abuse may have very complicated withdrawal symptoms that can be potentially dangerous. These individuals should always consult with a physician if they wish to discontinue their use of drugs.
- Many individuals who have received formal diagnoses of substance use disorders often have co-occurring mental health disorders that include anxiety disorders, depressive disorders, bipolar disorder, trauma- and stress-related disorders, personality disorders, etc. When individuals who already have issues with their emotional functioning are placed under the stress of a withdrawal syndrome, there is potential for serious issues to occur, such as trouble with judgment, potential self-harm, and overdose in an attempt to curb the symptoms associated with withdrawal. These individuals should always be monitored closely by medical professionals during recovery.
- The use of a tapering strategy or prescription medications in a withdrawal management program should only be attempted by a licensed physician. There are always a number of complications that can occur, including side effects, drug interactions, and idiosyncratic effects peculiar to the individual.
So-called “natural detox” approaches are often touted on the Internet as safe approaches to withdrawal management. Many of these remedies are supported by anecdotal reports that are not reliable and often based on pseudoscience. The actual empirical evidence for many of these procedures is lacking.
While some approaches can be useful, such as eating healthy or taking vitamins when combined with a formal physician-assisted detox program, these approaches are not recommended as standalone detox approaches. The majority of these approaches use untested methods, such as herbs, green tea, smoothies, and even Epson salt baths. The empirical evidence regarding the utility of these approaches and detox is lacking and, in some cases, indicates that they are not useful at all (e.g., Epson salt baths).
- What Drug Is the Most Difficult to Withdraw From?
This is a question that is often seen in many online forums. There are number of different answers to this question, and the actual answer is far simpler than most individuals imagine. The real answer to the question is:
The most difficult drug to undergo withdrawal from is the one that you are addicted to.
Because withdrawal symptoms are subjective, most individuals who undergo withdrawal will experience some difficulty. The actual length and severity of any withdrawal syndrome depends on a number of factors that include:
- The specific type of drug involved
- The amount of the drug the person typically used
- The length of time and how often the person used the drug
- The method of administration used
- Whether or not the person habitually used the drug with other substances of abuse
- How the person discontinues using the
- Individual differences in metabolism and emotional/psychological makeup
- Strategies to Assist with Detox
While it is generally not recommended that anyone attempt to detox from any substance without professional help, there are strategies that one can engage in that can assist a formal physician-assisted withdrawal management program. These include:
- Getting plenty of rest
- Remaining hydrated
- Eating healthy foods
- Getting support from others
- Asking for help when needed
- Engaging in gentle exercise, such as walking, if approved by a physician