What Drugs Require Inpatient Detox?

People who are considering inpatient detox often wonder whether it’s really necessary, and you may be wondering what kind of drug use requires this type of around-the-clock detox treatment. The Substance Abuse and Mental Health Services Administration (SAHMSA) recommends 24-hour detox care for several different substances of abuse. They do so for humanitarian and safety purposes; constant support and monitoring can help mitigate withdrawal symptoms, reduce the risk of complications, and facilitate the management of any issues that may arise. Further, regardless of the drug or drugs abused, anyone who has a severe addiction, a dual diagnosis, or a co-occurring medical condition may want to consider enrolling in an inpatient detox program.

Addictive Substances & Complicated Withdrawal

Anyone who is dependent on or addicted to a substance can benefit from inpatient detox. That being said, the concepts of dependence and addiction are somewhat distinct. Dependence develops when your body has adapted to the presence of the drug. People who develop a substance dependence may experience withdrawal symptoms with the abrupt cessation of or reduction in use. Addiction is a chronic condition characterized by compulsive drug use, despite knowing the negative consequences. People who are addicted are nearly always dependent, but dependence doesn’t necessarily imply addiction.¹

Withdrawal syndromes can manifest differently depending on what drug a person is dependent on or addicted to. Certain substances have dangerous and potentially fatal withdrawal symptoms, while others have milder, but still unpleasant symptoms. People at risk of severe or life-threatening withdrawal, which is known as “complicated withdrawal,” should be treated in an inpatient detox facility, or other 24-hour setting, such as a hospital, for monitoring and safety considerations.

Alcohol

Alcohol is one of the most commonly abused substances worldwide. Should problematic drinking result in the development of significant alcohol dependence, a person attempting to quit or cut back on their drinking may experience what’s known as an acute alcohol withdrawal syndrome.

Alcohol withdrawal can be very hazardous. It can result in symptoms that range in intensity from mild to severe. Alcohol withdrawal symptoms can include:^2,4,5

Seizures develop in around 25% of alcohol withdrawal cases and often begin within 24 hours of the last drink.⁵ Grand mal seizures are the type that most people usually think of when they imagine a seizure; this type of seizure occurs due to widespread, abnormal electrical activity throughout the brain. It can include a loss of consciousness, brief cessation of breathing, and muscle rigidity followed by muscle jerking; this is often followed by a brief period of sleep and awakening with confusion. Grand mal seizures can be particularly dangerous due to the risk of accidents, injuries, violence, or committing harm to oneself or others. Seizures and DTs are seen in cases of severe alcohol withdrawal and can lead to fatal consequences if not properly addressed.²

Other substances associated with severe withdrawal complications like DTs and grand mal seizures include benzodiazepines and other types of sedatives. The clinical course of sedative withdrawal is sometimes worsened by the fact that people who use benzodiazepines also often abuse alcohol.²

Benzodiazepines & Other Sedatives

Benzodiazepines are often prescribed to treat anxiety and panic disorders. This class of drugs includes brand name medications Xanax, Valium, and Ativan. Other prescription sedatives include barbiturates, such as phenobarbital, and sleep medications, such as Lunesta or Ambien.³

Withdrawal from these medications can result in a number of symptoms resembling those seen during alcohol withdrawal. In the most extreme cases of benzo withdrawal, people can develop delirium and seizures. Seizures are a particular concern because they can develop in the absence of any other withdrawal symptoms.²

Common withdrawal symptoms associated with benzodiazepines and other sedatives include:⁶

• Sweating or high pulse rate.
• Hand tremor.
• Insomnia.
• Nausea or vomiting.
• Temporary hallucinations.
• Psychomotor agitation, meaning increased purposeless and unintentional movements, such as fidgeting.
• Increased Anxiety.

People who are dependent on or addicted to benzodiazepines are often initially prescribed these medications to manage anxiety or panic. Withdrawal can lead to rebound anxiety, meaning those symptoms return, which can be quite distressing and may increase the likelihood that a person continues to use the drug in question.

Opioids

Unlike alcohol and sedative withdrawal, opioid withdrawal is not usually life-threatening. However, because the experience can be so violently unpleasant and, in some cases, is associated with significant complications, SAHMSA recommends a 24-hour supervised detox treatment or hospitalization for opioid withdrawal.²

While acute withdrawal symptoms usually subside over a period of 5-7 days, less acute symptoms, such as anxiety, anhedonia (an inability to experience pleasure), and insomnia, can last for weeks or even months.⁶

Opioid withdrawal is also associated with some physical and mental health complications. Some of the potentially dangerous complications of opioid withdrawal include^:2

• Severe gastrointestinal disturbances, such as excessive vomiting and diarrhea, which can lead to dehydration and electrolyte imbalance.
• Exacerbation of underlying cardiac illness due to increased blood pressure and rapid pulse.
• Fever, which can be a sign of an underlying infection, such as HIV or pneumonia.
• Exacerbation of any type of chronic pain condition due to reduced pain threshold and lack of pain relief provided by opioid use.
• Increased intensity of anxiety and panic disorders.

How Can Inpatient Care Help?

Inpatient detox is a multi-step process focused on providing the most comprehensive and supportive withdrawal treatment possible. When you arrive at a detox facility, you will undergo a complete evaluation by a medical or addiction professional. You will receive an assessment of your mental health, physical health, severity of your addiction, risk of complicated withdrawal, and other factors to help determine the appropriate course of action.

You may also need to provide blood or urine samples in order to evaluate for underlying health conditions, and, in some cases, undergo a genetic test, which can provide more information about how your individual makeup will impact the effectiveness of a medication.⁷ Testing provides your care team with the most information to best treat you and to create an individualized detox treatment plan.

Throughout the entire detox process, you will be treated with compassion, care, and sensitivity. You will receive around-the-clock support, monitoring, and treatment in order to prevent or address any symptoms and complications that may arise.

When applicable, you may receive medications to help alleviate withdrawal symptoms and cravings. Some of the commonly-used medications for withdrawal from specific substances include:^2,9

• Benzodiazepines for alcohol: These are anti-anxiety medications, like diazepam and chlordiazepoxide, which are helpful in managing withdrawal symptoms, as well as preventing or treating severe complications (such as seizures and extreme agitation).
• Long-acting benzodiazepines replace short-acting benzodiazepines: Long-acting benzos, such as diazepam and clonazepam, may be used to replace short-acting benzos, such as oxazepam or alprazolam, and then tapered gradually. Tapering a long-acting benzo replacement medication helps keep a person comfortable, safe, and stable while gradually reducing the amount of the drug in the person’s system, which can mitigate withdrawal symptoms.
• Methadone for opioids: Methadone is an opioid agonist, which means it activates opioid receptors, to suppress withdrawal symptoms and cravings.
• Suboxone for opioids: Suboxone is a combination of naloxone, an opioid antagonist, and buprenorphine, a partial opioid agonist. It is often used because it is more difficult to abuse than methadone or buprenorphine on its own.

Keep in mind that detox is not a form of treatment but rather the first step in the recovery process. Its goal is to manage the withdrawal process and achieve medical stabilization. In order to create a solid foundation for ongoing sobriety, it is advised to transition into a comprehensive addiction treatment program, which helps to address the underlying issues that lead to substance abuse, helps correct maladaptive behaviors, and fortifies your coping skills.

Sources

1. National Institute on Drug Abuse. (2007). The Neurobiology of Drug Addiction: 10. Addiction vs dependence.
2. Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 45. HHS Publication No. (SMA) 15-4131. Rockville, MD: Center for Substance Abuse Treatment.
3. National Institute on Drug Abuse. (2018). Commonly Abused Drugs Charts.
4. U.S. National Library of Medicine. (2017). MedlinePlus, Alcohol withdrawal.
5. Myrick, H. & Anton. R. (1998). Treatment of alcohol withdrawal. Alcohol Health and Research World, 22(1), 38-43.
6. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
7. Morris-Rosendahl, D. J., & Fiebich, B. L. (2004). The future of genetic testing for drug response. Dialogues in Clinical Neuroscience, 6(1), 27–37.
8. Center for Substance Abuse Treatment. (2006). Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 45. 1 Overview, Essential Concepts, and Definitions in Detoxification. Rockville, MD: Substance Abuse and Mental Health Services Administration.
9. World Health Organization. (2009). Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. 4. Withdrawal Management. Geneva: World Health Organization.