Detoxification

CONCEPTS OF
DETOXIFICATION AND
WITHDRAWAL
MANAGEMENT
Learning Objectives:
At the end of the session, the participants
should be able to:
1. understand the definition of Detoxification

2. understand the definition of Withdrawal
Management
3. learn the guiding principles in Detoxification
4. learn the basic concepts in the
Detoxification of some common
Substances of Abuse
Definition of Detoxification
• It is a set of interventions aimed at managing

acute intoxication and withdrawal.
• It denotes a clearing of toxins from the body of

the patient who is acutely intoxicated and/or
dependent on substances of abuse.
• Detoxification seeks to minimize the physical harm

caused by the abuse of substances.
Definition of Withdrawal
Management
• It refers to the medical and psychological
treatment of individuals who are experiencing a
withdrawal syndrome due to either reducing
their use of a particular drug or totally ceasing
their use.
• This definition was used by the World Health

Organization in 2009 and was most likely used
prior to that by other organizations.
Withdrawal Management:
Standard of Care (ASAM)
PHASES:
• Comprehensive Assessment and Diagnosis

• Withdrawal Management
• Treatment Planning
• Treatment Management
• Care Transitions and Care Coordination
• Continuing Care Management
Detoxification: Guiding
Principles / Assumptions
1. Detoxification alone is not sufficient

treatment for substance dependence but
it is one part of a continuum of care for
substance-related disorders.
2. The detoxification process consists of the

following three components:
a) Evaluation
b) Stabilization
c) Fostering patient readiness for and entry
into treatment
3. Detoxification can take place in a wide variety

of settings and at a number of levels of
intensity within these settings. Placement
should be appropriate to the patient’s needs.
4. Persons seeking detoxification should

have access to the components of the
detoxification process described above,
no matter what the setting or the level
of treatment intensity.
5. All persons requiring treatment for

substance use disorders should receive
treatment of the same quality and
appropriate thoroughness and should
be put into contact with a treatment
program for substance use disorders
after detoxification.
6. Ultimately, insurance coverage (PhilHealth)

for the full range of detoxification and follow-
up treatment services is cost-effective. If
reimbursement systems do not provide
payment for the complete detoxification
process, patients may be released
prematurely, leading to medically or
socially unattended withdrawal.
7. Patients seeking detoxification services have

diverse cultural and ethnic backgrounds as
well as unique health needs and life
situations. Organizations that provide
detoxification services need to ensure that
they have standard practices in place to
address cultural diversity.
8. A successful detoxification process can be

measured, in part, by whether an individual
who is substance dependent enters, remains
in, and is compliant with the treatment
protocol of a substance abuse
treatment/rehabilitation program after
detoxification.
Detoxification: Overarching
Principles for Care during
Detoxification
• Detoxification services do not offer a “cure”

for substance use disorders; they are often a
first step toward recovery and a “first door”
through which patients pass to treatment.
• Substance use disorders are treatable and

there is hope for recovery.
Detoxification
• Substance use disorders are brain disorders

and not evidence of moral weakness.
• Patients should be treated with respect and

dignity at all times.
Detoxification
• Patients should be treated in a

nonjudgmental and supportive manner.
• Services planning should be completed in

partnership with the patient and his or her
social support network, including family,
significant others, or employers.
Detoxification
• All health professionals involved in the care

of the patient will maximize opportunities to
promote rehabilitation and maintenance
activities and to link the patient to
appropriate substance abuse treatment
immediately after the detoxification phase.
Detoxification
• Active involvement of the family and other
support systems, while respecting the
patient’s right to privacy and confidentiality,
are to be encouraged.
• Patients should be treated with due

consideration for individual background,
culture, preferences, sexual orientation,
disability, vulnerabilities, and strengths.
Detoxification: Biomedical
and Psychosocial Issues
• It presents an opportunity to intervene during
a period of crisis and to encourage a client to
make changes in the direction of health and
recovery.
• Hence, a primary goal of the detoxification

staff should be to build a therapeutic alliance
and motivate patients to enter treatment.
This process should begin as the patient is
being medically stabilized.
Detoxification: Symptoms and
Signs of Conditions That Require
Immediate Medical Attention
• Change in mental status

• Increasing anxiety
• Hallucinations
• Temperature greater than 100.4⁰F/38⁰C
(these patients should be considered
potentially infectious)
• Significant increases and/or decreases in
blood pressure and heart rate
Detoxification: Symptoms and
Signs of Conditions That Require
Immediate Medical Attention
• Insomnia
• Abdominal pain
• Upper and lower gastrointestinal bleeding
• Changes in responsiveness of pupils
• Heightened deep tendon reflexes and ankle
clonus, a reflex beating of the foot when
pressed rostrally, indicating profound central
nervous system irritability and the potential
for seizures
Detoxification: Immediate
Mental Health Needs
Suicidality
• Patients receiving detoxification services

should be evaluated for suicide risk.
• During acute intoxication and withdrawal,

it is important to provide an environment
that minimizes opportunities for suicide
attempts.
Mental Health Needs
Suicidality
• Frequent safety checks should be

implemented.
• Patients at risk for suicide should be

placed in areas monitored by staff.
Mental Health Needs
Anger and aggression
• All patients who are intoxicated should be

considered potentially violent.
• Symptoms associated with increased risk

for violence include hallucinations,
paranoia, anxiety, and depression.
• Physical restraint should be used as a last

resort.
Detoxification: Initial Biomedical
and Psychosocial Evaluation
Domains
Biomedical Domain
• General health history

• Mental status
• General physical assessment with
neurological exam
• Vital Signs (should be monitored
throughout detoxification)
Domains
Biomedical Domain
• Patterns of substance abuse

• Urine and toxicology screen for commonly
abused substances
• Past substance abuse treatments or
detoxifications
Domains
Psychosocial Domain
• Demographic features
• Living conditions
• Violence, suicide risk
• Financial situation
• Dependent children / Family
• Legal status
• Physical, sensory, or cognitive disabilities
Detoxification: Strategies for
Engagement and Recovery
• Educate
• Use Support Systems the Patient on the
Withdrawal Process
• Maintain a Drug-Free Environment
• Consider Alternative Approaches and
Motivational Enhancement
• Foster a Therapeutic Alliance
Detoxification: Drug Tests and
Biochemical Markers
• Blood alcohol content

• Breath alcohol levels
• Urine drug screens
• Gamma-glutamyltransferase (GGT)
• Carbohydrate-deficient transferrin
Detoxification: Drug Tests and
Biochemical Markers
• Mean corpuscular volume (MCV)

• Alcohol metabolites
• Toxicological drug tests for general and
specific opiates, stimulants, hallucinogens,
benzodiazepines, barbiturates, marijuana,
etc.
Detoxification: Stimulants
Stimulant withdrawal symptoms
• Depression
• Hypersomnia or insomnia
• Fatigue
• Anxiety
• Irritability
Stimulant withdrawal symptoms
• Poor concentration
• Psychomotor retardation
• Paranoia
• Drug craving
Medical complications of stimulant withdrawal
• Stimulant withdrawal is not usually

associated with medical complications.
• While both cocaine and amphetamines (such

as methamphetamine) often produce
depression in users during withdrawal, the
period of depression experienced by
amphetamine users is more prolonged and
may be more intense.
• Consequently, amphetamine users should be

monitored closely during detoxification for
signs of suicidality and treated for depression
if appropriate.
• Some patients with recent cocaine and

alcohol use can experience persistent
cardiac complications, including prolonged
QTc interval and vulnerability for arrhythmia
and myocardial infarction through the
production of cocoethylene.
• Seizures may also be a complication of

stimulant abuse and can occur during
detoxification.
Management of withdrawal with medications for

stimulant withdrawal
Although there are no medications proven to treat

stimulant withdrawal, researchers have investigated
medications for cocaine detoxification:
• Disulfiram and Amantadine may help reduce

cocaine use in patients with more severe
withdrawal symptoms.
• Modafinil, an anti-narcolepsy agent with

stimulant-like action, is currently under
investigation by one research group as a
cocaine detoxification agent.
• Antidepressants can be prescribed for the

depression that often accompanies
methamphetamine or other amphetamine
withdrawal.
Detoxification: Inhalants/
Solvents
Withdrawal from Inhalants / Solvents
• Dependence on inhalants and subsequent

withdrawal symptoms are both relatively
uncommon phenomena.
• There are no specific or characteristic withdrawal

symptoms that would include all drugs in the
inhalant class.
Solvents
• There are no specific assessment instruments

available to measure inhalant withdrawal
symptoms.
• Most inhalants produce some neurotoxicity

with cognitive, motor, and sensory
involvement.
• Damage to internal organs including the heart,

lungs, kidneys, liver, pancreas
Solvents
Management of Inhalant withdrawal
• It is crucial to provide the patient with an

environment of safety that removes him
or her from access to inhalants.
Solvents
• Patients presenting with only inhalant withdrawal

are unusual; clinicians should promptly ascertain if
the patient has been abusing other substances
and proceed with appropriate detoxification as
clinically indicated.
• No systemic detoxification protocol has been

established for inhalant abuse.
Detoxification: Opioid Intoxication
and Withdrawal
Opioid intoxication signs
• Slow pulse
• Low blood pressure
• Low body temperature
• Sedation
• Pinpoint pupils
• Slowed movement
• Slurred speech
• Head nodding
and Withdrawal
Opioid intoxication symptoms
• Euphoria
• Pain-killing effects
• Calmness
and Withdrawal
Opioid withdrawal signs
• Fast pulse
• High blood pressure
• High body temperature
• Insomnia
• Enlarged pupils
• Abnormally heightened reflexes
• Sweating
and Withdrawal
Opioid withdrawal signs
• Gooseflesh
• Increased respiratory rate
• Tearing (as in crying)
• Yawning
• Runny nose
• Muscle spasms
and Withdrawal
Opioid withdrawal symptoms
• Abdominal cramps
• Nausea
• Vomiting
• Diarrhea
• Bone and muscle pain
• Anxiety
Detoxification: Opioid Withdrawal
Management of withdrawal without medication
• It is not recommended that clinicians attempt

to manage significant opioid withdrawal
symptoms without the effective detoxification
agents discussed below.
• Even mild levels of opioid use commonly

produce uncomfortable levels of withdrawal
symptoms.
• Management of withdrawal without

medications can produce needless suffering.
Management of opioid withdrawal with

medications
• Methadone
• Clonidine
• Buprenorphine
Detoxification: Intoxication and
Withdrawal from Benzodiazepines and
other Sedative-Hypnotics
General points
• Management of benzodiazepines and other

sedative-hypnotics in overdose is in part
supported following principles of advanced
cardiac life support, with attention to ventilation.
• Removal of benzodiazepines from the

gastrointestinal tract using lavage and a cathartic
is generally carried out, particularly if the
overdose is recent.
• Flumazenil (Romazicon) is a competitive

antagonist that acts as a benzodiazepine receptor.
It can reverse the sedative and overdose effects of
benzodiazepines but not of alcohol or other
sedative-hypnotics.
• Assessing the severity of benzodiazepine and

other sedative-hypnotic abstinence syndrome is
based primarily on information from the patient,
significant others, and physical assessment.
Management of withdrawal with medication
• One strategy that is appropriate is to begin with a

slow taper of the benzodiazepine that the patient
is already taking. This taper may be conducted
over several weeks or perhaps even months.
• Switching to another benzodiazepine in a patient

who has had a serious abuse problem with his
primary agent may be therapeutic.
• Switching to another benzodiazepine with a long

half-life can be effective; chlorodiazepoxide and
clonazepam are recommended.
• Switching to a long-acting barbiturate like

Phenobarbital can be effective.
• A variety of cognitive and behavioral techniques

have been proposed to assist a medication taper.
• Anticonvulsants such as carbamazepine and

valproate, as well as sedating antidepressants
such as trazodone and imipramine, have been
advocated for use in withdrawal.
• Preparing patients for starting detoxification

during a period of low external stressors, with
patient commitment to tapering and a plan to
manage underlying anxiety disorders, are also
important in detoxification.
Detoxification: Club Drugs
Hallucinogens
• They are a broad group of substances that

can produce sensory abnormalities and
hallucinations.
• They are also referred to as psychedelics and

psychomimetics.
• They include LSD, mescaline, MDMA, MDA,

and DOM.
• The prominent effects during intoxication are

sensory distortions with illusions and
hallucinations; visual distortions are more
common than auditory or tactile ones.
• “Bad trips” involve anxiety including panic

attacks, paranoid reactions, anger, violence,
and impulsivity.
• Withdrawal syndromes have not been

reported with hallucinogens.
• Acute intoxication and bad trips usually can

be managed with placement of the individual
in a quiet, non-stimulating environment with
immediate and direct supervision so that the
patient.
Gamma-hydroxybutyrate (GHB)
• GHB intoxication may look like alcohol or

sedative-hypnotic intoxication, and case
reports of GHB withdrawal have occurred.
• Management of withdrawal has been with

supportive care and benzodiazepines such as
lorazepam.
Ecstasy
• Patients using ecstasy (MDMA) or related

compounds frequently are hyperactive and
hyper-verbal, reporting heightened tactile and
visual sensations.
• Hyperthermia, dehydration, water intoxication

with low sodium rhabdomyolysis, renal failure,
cardiac arrhythmia, and coma have been
reported.
• Clinicians are likely to have to manage

complications of intoxication and overdose but
not withdrawal.
Ketamine and PCP (Phencyclidine)
• Withdrawal symptoms from PCP include

depression, drug craving, increased appetite, and
hypersomnolence.
• In clinical settings, syndromes of acute

intoxication with hallucinations, delusions,
agitation, and violence are the most pressing
problems.
• In clinical settings, ketamine and PCP require

management for the agitation and psychotic
features produced during acute use; occasionally
oral or parenteral uses of sedating medications
such as benzodiazepines will be required.
• Occasionally patients will have such large

overdoses that they will require airway
management and ventilatory support for some
hours.
Detoxification: Alcohol Intoxication
Blood alcohol level is 20 – 100 mg percent
• Mood and behavioral changes

• Reduced coordination
• Impairment of ability to drive a car or operate
machinery
• Reduced coordination of most activities

• Speech impairment
• Trouble walking
• General impairment of thinking and judgment
• Somnolence, combative or “psychotic”
behavior
• “Normal” mental status
• Marked impairment of thinking, memory, and

coordination
• Marked reduction in level of alertness
• Memory blackouts
• Nausea and vomiting/aspiration
• Worsening of above symptoms with reduction

of body temperature and blood pressure
• Excessive sleepiness/comatose
• Amnesia
• Nausea and vomiting/aspiration
• Death
• Difficulty waking the patient (coma)

• Serious decreases in pulse, temperature,
blood pressure, and rate of breathing
• Urinary and bowel incontinence
• Death
Detoxification: Alcohol Withdrawal
• Restlessness, irritability, anxiety, agitation

• Anorexia, nausea, vomiting
• Tremor, elevated heart rate, increased blood
pressure
• Insomnia, intense dreaming, nightmares
• Poor concentration, impaired memory and
judgment
• Increased sensitivity to sound, light, and tactile
sensations
• Hallucinations (auditory, visual, or tactile)

• Delusions, usually of paranoid or persecutory
varieties
• Grand mal seizures
• Hyperthermia
• Delirium/disorientation with regard to time,
place, person, and situation; fluctuation in level
of consciousness
Management of alcohol withdrawal without

medication
• Indications for the management of alcohol

withdrawal without medication have not been
established through scientific studies or
evidence-based methods.
• The course of alcohol withdrawal is unpredictable;

it is impossible to tell who will or will not
experience life-threatening complications.
• Positive aspects of the non-medication approach

are that it is highly cost-effective and provides
inexpensive access to detoxification for individuals
seeking aid.
Deciding whether or not to use medical

management for alcohol withdrawal requires that
patients be separated into three groups:
• Patients who have a history of the most

extreme forms of withdrawal, that of seizures
and/or delirium. The medication treatment of
this group should proceed as quickly as
possible.
• Patients who are already in withdrawal and

demonstrating moderate symptoms of
withdrawal also require immediate medication.
• Patients who may still be intoxicated, or who

have, at the time of admission, been abstinent
for only a few hours and have not developed
signs or symptoms of withdrawal.
Benzodiazepine treatment for alcohol withdrawal
• Loading dose of a benzodiazepine

• Symptom-triggered therapy
• Gradual, tapering doses
• Single daily dosing protocol
Other medications
• Barbiturates
• Anticonvulsants
• Beta blockers/alpha adrenergic agonists
• Antipsychotics
• Relapse prevention agents
Management of Delirium and Seizures
DTs
• Giving the patient a benzodiazepine should not

be delayed by waiting for the return of
laboratory studies, transportation problems, or
the availability of a hospital bed.
• Once full DTs have developed, they tend to

run their course despite medication
management.
• Patients presenting in severe DTs should have

emergency medical transport to a qualified
emergency department and generally will
require hospitalization.
Seizures
• They usually occur within the first 48 hours

after cessation or reduction of alcohol, with
peak incidence around 24 hours.
• Someone experiencing a seizure is at greater

risk for progressing to DTs, whereas it is
extremely unlikely that a patient already in DTs
will also then experience a seizure.
• The occurrence of an alcohol withdrawal

seizure happens quickly, usually without
warning to the individual experiencing the
seizure or anyone around him.
• Predicting who will have a seizure during

alcohol withdrawal cannot be accomplished
with any great certainty.
• Patients having a seizure can be treated with

intravenous (IV) diazepam or lorazepam and
advanced cardiac life support protocol
procedures.
• Patients who have had a single witnessed or

suspected alcohol withdrawal seizure should
be immediately given a benzodiazepine,
preferably with IV administration.
• Benzodiazepine and/or barbiturate

intoxication needs to be treated and
assessed differently, given the potentially
life-threatening implications of withdrawal
from either substance in combination with
each other and/or alcohol.
Wernicke-Korsakoff’s Syndrome
• It is composed of Wernicke’s encephalopathy

and Korsakoff’s psychosis.
• Wernicke’s encephalopathy is an acute

neurological disorder featuring oculomotor
dysfunction (bilateral abducens nerve palsy—
eye muscle paralysis), ataxia (loss of muscle
coordination), confusion, and weakness.
• Korsakoff’s psychosis is a chronic neurological

condition that includes retrograde and ante-
grade amnesia (profound deficit in new
learning and remote memory) with
confabulation (patients make up stories to
cover memory gaps).
• Both syndromes are related to thiamine

deficiency.
• Thiamine initially is given parenterally (in a

manner other than through the digestive
tract, as by intravenous or intramuscular
injection). Afterward, oral administration is
the treatment of choice.
• Always give thiamine prior to glucose

administration.
Learning Objectives:
At the end of the session, the participants
should be able to:
1. understand the definition of Detoxification

2. understand the definition of Withdrawal
Management
3. learn the guiding principles in Detoxification
4. learn the basic concepts in the
Detoxification of some common
Substances of Abuse

Detoxification

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CONCEPTS OF

1. understand the definition of Detoxification

• It is a set of interventions aimed at managing

• It denotes a clearing of toxins from the body of

• Detoxification seeks to minimize the physical harm

• This definition was used by the World Health

• Comprehensive Assessment and Diagnosis

1. Detoxification alone is not sufficient

2. The detoxification process consists of the

3. Detoxification can take place in a wide variety

4. Persons seeking detoxification should

5. All persons requiring treatment for

6. Ultimately, insurance coverage (PhilHealth)

7. Patients seeking detoxification services have

8. A successful detoxification process can be

• Detoxification services do not offer a “cure”

• Substance use disorders are treatable and

• Substance use disorders are brain disorders

• Patients should be treated with respect and

• Patients should be treated in a

• Services planning should be completed in

• All health professionals involved in the care

• Patients should be treated with due

• Hence, a primary goal of the detoxification

• Change in mental status

• Patients receiving detoxification services

• During acute intoxication and withdrawal,

• Frequent safety checks should be

• Patients at risk for suicide should be

• All patients who are intoxicated should be

• Symptoms associated with increased risk

• Physical restraint should be used as a last

• General health history

• Patterns of substance abuse

• Blood alcohol content

• Mean corpuscular volume (MCV)

Stimulant withdrawal symptoms

Stimulant withdrawal symptoms

Medical complications of stimulant withdrawal

• Stimulant withdrawal is not usually

• While both cocaine and amphetamines (such

• Consequently, amphetamine users should be

• Some patients with recent cocaine and

Medical complications of stimulant withdrawal

• Seizures may also be a complication of

Management of withdrawal with medications for

Although there are no medications proven to treat

• Disulfiram and Amantadine may help reduce

• Modafinil, an anti-narcolepsy agent with

• Antidepressants can be prescribed for the

Withdrawal from Inhalants / Solvents

• Dependence on inhalants and subsequent

• There are no specific or characteristic withdrawal

• There are no specific assessment instruments

• Most inhalants produce some neurotoxicity

• Damage to internal organs including the heart,

Management of Inhalant withdrawal

• It is crucial to provide the patient with an

• Patients presenting with only inhalant withdrawal

• No systemic detoxification protocol has been