Medically Supervised Withdrawal (Detoxification) from Opioids (2023)

June 11, 2021

Overview

• Individuals who are chronically exposed to opioids develop physical dependence and experience withdrawal symptoms if the daily dose of opioids is reduced or stopped abruptly. Detoxification is a process of removing physiological dependence while managing opioid withdrawal.
• Detoxification alone is not a treatment for OUD and increases an individual’s risk for relapse, overdose and death when not followed with medications for opioid use disorder (MOUD).
• Several medications help to reduce the symptoms of opioid withdrawal during the detoxification process.
• Determining the approach to manage opioid withdrawal for individual patient’s depends upon their plans for treatment.
• The goal must be to maximize the probability of long term treatment engagement and to minimize the impact of OUD on the patient’s health and functioning.

What is Detoxification

Medically supervised withdrawal or “detoxification” is the process of taking a person off an opioid on which he or she is physically dependent. The term detoxification is usually called medically supervised withdrawal management to destigmatize the process. The process can be fast or slow and can be done under a variety of levels of care and supervision. “Detox” works differently in different people and in different treatment plans. When supervised by a physician, medications are available to help make this process both safer and more comfortable.

Is Detoxification Always the Best Thing for People with Opioid Use Disorder?

Although it seems intuitive to start treatment for opioid use disorder with “detoxing” and stopping all opioids, this is not always the best course of action. We know that people who complete a detox soon after stopping using illicit opioids have a very high chance of returning to opioid use. In some studies, more than 90% people who completed detoxification returned to opioid use over the next few months. (1) In most cases, it is therefore important to focus on the long-term plan for treatment with a medication for opioid use disorder and only then to consider how to approach detoxification. The process of “detoxification” commonly utilized in substance use treatment has no clinical utility in the absence of a plan for maintenance treatment and has no evidence for improving outcomes unless serving as a bridge to long term follow up options. “Detoxing” a person off of opioids without clear motivation by the individual to maintain abstinence or without a follow up plan that is likely to maintain sustained abstinence through the use of MAT increases the patient’s risk for overdose and death in the case of any return to use.(2)

What are the Goals of Detoxification?

However, a good detoxification program accomplishes many important goals in a person’s recovery:[3]

1. Rid the body of its daily, physical dependence on opioid drugs
2. Lessen or relieve the pain of withdrawal
3. Address any other medical problems
4. Prevent relapse by:
   • Providing help during the most difficult parts of withdrawal
   • Connecting patients with continued treatments
   • Educating patients about their risk of relapse and ways to stay healthy, to help prevent relapse
5. Facilitate induction onto medication for opioid use disorder for continued treatment.

What is a Successful Detoxification?

• Detoxification is only the first stage of opioid addiction treatment!
• Few patients can continue to stay completely away from opioids without continued treatment with medications immediately after detox.
• Continued treatment after detox can help a person regain mental and physical health and well-being. Besides helping patients to avoid returning to drug use, continued treatment can assist patients with larger goals of improving employment, healing relationships, and possibly addressing past criminal behavior.
• Because of the high risk for relapse within opioid addiction, detoxification may be needed more than once in a person’s course of treatment.[4]

What are the Different Kinds of Detoxification Programs?

There are many kinds of detoxification programs. Detox programs can occur in inpatient, residential, day, or outpatient settings. Treatment can and should look different for people with different needs, preferences, and personalities. Because medications for opioid use disorder are so important to recovery, programs that discourage or do not offer these medications after detoxification should be avoided.

Opioid withdrawal is generally less medically dangerous than withdrawal from other substances, like sedative-hypnotics or alcohol. However, detoxification can still be very difficult and uncomfortable, and attempting detoxification without medical help often results in relapse. Some patients who can’t complete detoxification on an outpatient basis may be admitted to a medical facility as inpatients to complete withdrawal. Inpatient detoxification is also recommended for patients physically dependent on more than one kind of drug, or for patients with complicated medical issues.[5]

Detoxification in a medical setting is often accompanied by starting patients on medication to lessen withdrawal symptoms and prevent relapse. See later section: “Detoxification and Agonist Maintenance.”

After Detoxification: What’s Next?

The best addiction treatments include continued treatment after detoxification. A patient should work with his/her doctor to find the kind continuing treatment that is best based on the patient’s needs, safety concerns, and local resources. The patient’s finances, insurance, criminal justice status, past responses to treatments, and any co-occurring psychiatric disorders may also be considered.

Treatment options include both inpatient and outpatient treatment, individual or group therapy, and/or medications. Patients should check with their insurers to find out which treatments are covered, and to locate doctors in their area that provide covered addiction services.

Some inpatient programs do not end after detoxification. In longer-term inpatient programs, patients spend extra time in a medical facility learning about substance abuse disorders, to confront and address the negative effects of addiction in their lives, ways to make lifestyle changes, and coping strategies to prevent relapse.

[1] Weiss RD, Potter JS, Fiellin DA, Byrne M, Connery HS, Dickinson W, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011;68(12):1238-46.

[2] Nunes EV, Shulman M. Commentary on Stein et al. (2020): Whither detoxification in the face of the opioid epidemic? Addiction. 2020;115(1):95-6.

[3] Polydorou, S., & Kleber, H. D. (2008). Detoxification of Opioids. In M Galanter & H Kleber (Eds.), Textbook of Substance Abuse and Treatment (4^th ed.) Arlington, VA: American Psychiatric Publishing.

[4] Weiss, R. D., Potter, J. S., & Iannucci, R. A. (2008). Inpatient Treatment. In M. Galanter & H. Kleber (Eds.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.

[5] Weiss et al. Inpatient Treatment.

[6] Weiss et al. Inpatient Treatment.

[7] PCSS-MAT