Detoxification Is Not Treatment

In In the News by marietta

Article shared with permission from the RCORP-TA Project

Detoxification is not a treatment for Opioid Use Disorder (OUD). So, what is the role of detoxification in your community’s response to the opioid epidemic? In this best practices brief, we’ll explain detoxification and its limited role in evidence-based OUD treatment practices.

Demystifying Detoxification
Detoxification is the medical management of acute withdrawal due to physiological dependence on a substance. Detoxification is not a treatment for addiction because detoxification does not change the underlying substance use disorder. The medical management of acute withdrawal may be necessary to begin the process of treating addiction, but this isn’t always the case. For example, detoxification services are critical to the safe management of alcohol and benzodiazepine use disorder, but the utility of detoxification in OUD is limited by the kind of treatment used for the OUD itself. The standard of care for OUD (i.e., rather than for withdrawal) is the use of medication for OUD (MOUD): buprenorphine, methadone, or naltrexone. As we’ll see below, whether detoxification should be part of your practice will depend on what MOUD you use.
There is a long-standing customary practice of providing medical management of acute withdrawal from opioids followed by behavioral and other psychosocial supports in either an outpatient or residential setting without providing medication. This practice is not supported by evidence. One study showed a quarter of people relapsed on their day of discharge from detoxification for OUD and 65% relapse within a month. Another study found 91% of people who completed detoxification for OUD and received “abstinence-oriented” treatment relapsed, 59% relapsed within a week of discharge and 80% relapsed within a month of discharge from residential detox. While some patients may choose this path, it is not a best practice for OUD treatment and should never be the only option.

What Should We Be Doing, Then?
Medication is the first line of treatment for OUD because they reduce opioid use, disease transmission, criminal behavior, and most importantly: mortality. Medication improves retention in treatment so these benefits are sustained and can support recovery. Whether detoxification should be a part of OUD treatment will depend on which of the MOUD you prescribe. Medical management of acute withdrawal is not necessary for patients who chose buprenorphine or methadone and should not be required. Buprenorphine and methadone can be started after a period of withdrawal lasting a few hours to a day. In the case of methadone, the treatment provider is required to document that the patient is opioid dependent by observing and documenting classic signs and symptoms of opioid withdrawal. (This requirement was put in place to avoid causing opioid dependence by providing methadone to someone who was not already dependent due to opioid use.) A patient who is starting buprenorphine must also be in withdrawal from opioids, typically for a few hours. If buprenorphine is taken by someone who is opioid dependent while they are not in withdrawal, it will quickly put them into very intense withdrawal that will last for several hours. While not typically dangerous, experiencing sudden onset of acute withdrawal triggered by buprenorphine is traumatic and may deter the person from engaging in treatment.
However, detoxification is necessary for patients who chose MOUD with naltrexone, an opioid antagonist (or blocker). Safe administration of naltrexone requires that the patient must be abstinent from opioids for 7 days—14 days in the case of longer acting opioids such as methadone. Medically managed withdrawal may take place in an inpatient (i.e., hospital) setting for patients who have other serious medical or mental health problems or who are withdrawing from multiple substances. People who are withdrawing only from opioids or who are otherwise in good health could undergo medically managed withdrawal in an appropriately staffed outpatient or residential setting.
During the period between completing detoxification and receiving naltrexone, patients should receive treatment to provide relief from any protracted withdrawal symptoms along with intensive psychosocial and recovery support to protect them from relapse. Overdose prevention education and naloxone should also be provided to prevent fatal overdose if relapse occurs. If relapse is imminent, the best course of action may be to start buprenorphine rather than continue to wait the required number of days to be able to safely administer naltrexone.

Resources:
For guidance about evidence-based detoxification protocols, see Chapter 4 (Withdrawal Management) of the World Health Organization’s Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings.
For information about prescribing naloxone, please visit Prescribe to Prevent, which includes information compiled by several naloxone access and overdose prevention advocates to help providers learn how to make naloxone available to their patients.