Before Drug Rehab: Learn Your Detox Options

You probably can’t stay clean and sober until you learn some recovery skills; that’s basically why you get addiction treatment - to learn the skills you need to avoid relapse and maintain your recovery.

But you can’t settle down and start learning while experiencing uncomfortable, or even life-threatening, withdrawal symptoms.

So you need to go through withdrawals first, before you can start learning how to stay sober and you need to stay as safe and comfortable as possible during this process.

You enroll in a detox program to:

1. Stay safe and comfortable
2. Preserve your dignity
   
3. Make it through the acute withdrawal period to a point where you’re stable enough to start participating in an addiction treatment program

Do you need detox?

Read on to find the answers to questions like:

• Do you need detox help?
• What is detox, where can you get it and how much does it cost?
• What happens in detox?
• What are some different types of detox programs and how do you know which kind you need?

What Is Detoxification?

Detox is the process and interventions associated with transitioning from a state of dependence/intoxication - through the acute (first stage) of withdrawal symptoms - to relative stability.

Withdrawal symptoms can be uncomfortable or even dangerous, so people often require nursing supervision and medications to alleviate discomfort and improve safety.

Ideally, a detox program preserves your dignity and keeps you as safe and comfortable as possible during the withdrawal process.¹

Where Can You Get Detoxed?

Once you decide you want to detox you have a number of options. You can detox with/at

• Your family doctor (your family doctor can provide ambulatory [outpatient] detoxification services, and if she can’t, she can refer you to an appropriate level of care)
• A hospital emergency room (especially when withdrawal symptoms can be life-threatening, such when detoxing from alcohol or sedative hypnotics...simply show up and tell them what you need to do)²
  
• A freestanding detox clinic
• A freestanding substance abuse treatment facility
• Intensive outpatient and partial hospitalization programs
• An acute care or psychiatric hospital³

To find facilities in your area that provide detoxification services, visit the Substance Abuse and Mental Health Agency’s (SAMHSA) Treatment Locator Tool.

With this tool you can search for substance abuse treatment within a radius around your home address or zip code. With the advanced search, you can select to search for facilities that provide detox.

Once you have a list on your computer screen, a couple of hours on the phone calling local facilities is all that’s needed to get started!

Finding Services

The squeaky wheel gets the grease…

Demand for services often exceeds supply, especially demand for free or more affordable services.

It is possible that, at this very moment, there are no detox facilities in your area willing to admit another client.

However, you cannot claim an inability to find a detox slot until you have actually done some leg-work and searched for it.

If you’re serious about getting detoxed, no matter what your financial situation, do not give up until you have:

• Spoken to someone at your county health/mental health or substance abuse office to ask for treatment and, if necessary, to get put on a waiting list for care
• Spoken to your family doctor (if you have one) about your options and to ask for a referral
• Done a search for detox clinics on the SAMHSA Treatment Locator website, and then called each one in your area (If you need low cost services, ask each facility if they can accept payment on a sliding scale based on your income)
• Traveled to local hospital emergency rooms to request services

The 2 Basic Models of Detox

Drug and alcohol detox centers operate on either a medical detox or social detox model of care.

Medical Detox

In a medical detox, doctors and nurses supervise your withdrawal and doctors will prescribe medications, as necessary, to improve safety and increase comfort.

Social Detox

In a social model detox, staff are not necessarily medically trained (they usually are not). Social model detoxes tend to be cheaper and based in less clinical environments. Staff help clients through the withdrawal process with group and individual counseling, coordination of care and by providing a supportive, comfortable and drug and alcohol free environment.

Because of their non medical nature, social detox clinics are not equipped to handle clients with severe physical dependencies to alcohol or sedative hypnotics, like benzodiazepines or Z drugs.⁴

The Three Essential Steps of the Detox Process

No matter what type of detox facility you choose and no matter what substance or substances you must withdraw from, all people going through the withdrawal process must complete the same three essential steps.

1. Evaluation
2. Stabilization
3. Preparation for Continuing Treatment

1. The Evaluation

You must get evaluated. The assessment professional will evaluate your current state of intoxication/withdrawal, assess for current physical or mental illness and gather information on your social and psychological situation and functioning.

2. Stabilization

Stabilization is the process of transitioning from intoxication - through withdrawal - to a clean and sober state of stability.

3. Preparation for Future Addiction Treatment

Although many people choose to exit care after detox, detox alone does not teach you how to avoid relapse or build a better life of sobriety.

For this reason, detox staff will emphasize the benefits of continuing treatment and prepare you to transition into an appropriate level of care.

The 5 Levels of Detox

Not everyone needs the same types of interventions. Some people can withdrawal quite safely at home, with only minimal outpatient support, while on the other end of the spectrum, some people need around-the-clock hospital supervision.

But how can you know what you need?

Well, you probably can’t, but don’t worry, it’s not your job to self-diagnose.

Once you initiate the detox process, such as by checking in at a detox clinic or by going to a local hospital, you will receive a professional intake evaluation. The intake professional will then recommend a level of care, based on the results of this intake examination.

According to the American Society of Addiction Medicine (ASAM) the 5 levels of detox care are:

Level 1 - Ambulatory Detoxification without Extended Onsite Monitoring

This is the least intensive level of detox.

At this level you detox at home, but check-in with your doctor or with an outpatient detox program at scheduled intervals (such as by daily check-up appointments).

Level 2 - Ambulatory Detoxification with Extended Onsite Monitoring

In level 2, you still sleep at home each night, but you spend a significant period of each day under nursing observation at a centralized detox site.

Level 3 - Clinically Managed Residential Detoxification

A level 3 withdrawal is a 24 hour a day social detox that occurs in a residential facility. Staff members in a level 3 detox have no medical training.

Level 4 - Medically Monitored Inpatient Detoxification

People in a level 4 detox require 24 hour a day medical monitoring, such as in a medical detox clinic.

Level 5 - Medically Managed Intensive Inpatient Detoxification

The most intensive level of detox, people in a level 5 detox require significant medical monitoring. A level 5 detox occurs in an acute care hospital setting.

Determining an Appropriate Level of Care

To build a level of care determination, as assessment professional will evaluate your situation across a number of domains, and then make a subjective decision based on your needs, resources and abilities.

Intake workers typically assess your situation across 6 variables. These 6 variables are:

1. Current Intoxication and Predicted Withdrawal Severity

Someone who has a history of complicated withdrawals and who enters the detox process with a blood alcohol level of 0.35 likely needs a higher level of care than someone who is detoxing for the first time and who walks in relatively sober.

2. Health Problems and Medical Complications

A person with uncontrolled high blood pressure, for example, might require augmented medical monitoring during sedative withdrawal.

3. The Co-Presence of an Emotional, Behavioral or Cognitive Complication

Psychiatric problems and thinking abilities can affect a person’s ability to stick with detox. For example, while a cocaine user might normally try detoxing on an outpatient basis, a person with uncontrolled ADD might require the additional structure of a social model residential program.

4. Readiness to Change

People who really want to change may not require as much assistance as those who display less motivation.

5. Relapse History and Ability to Maintain Abstinence

People who can’t maintain even short periods of abstinence won’t do well in an ambulatory detoxification protocol.

6. Living Situation

Someone who is homeless, for example, or living in a very unstable home, might require the structure and safety of a residential facility.

Complicating Factors 

And if things weren’t complex enough - in addition to the 6 dimensions outlined above, additional variables can sometimes further complicate a treatment recommendation, such as:

• Needing to take care of dependent children
• Being unable to travel to and from an outpatient center each day
• Lacking financial resources
• Being unable to sign or understand informed consent
• Displaying psychosis or violent or aggressive behaviors
• Having suicidal thoughts
• Language or cultural barriers
• Physical or sensory disabilities
• Legal issues

Medical Detox Costs

In Feb 2011, Open Minds Consulting surveyed 15 private medical detox facilities on pricing information. They found that as of 2011, the average price for 24 hours of inpatient medical detox was $1707.00 per day.⁵

Note: costs will vary, insurance can offset much or all of the expense and many facilities will offer services on a sliding scale based on your income and ability to pay.

When to Get Immediate Medical Attention

Note: withdrawing from alcohol or sedative hypnotics without medical supervision is dangerous. To be blunt - you could die. Withdrawal symptoms can go from moderate to life-threatening very quickly and it is difficult to predict in advance who will experience severe withdrawals. Do not do this on your own.

However, if for any reason you find yourself going through the withdrawal process without medical assistance, be on the look-out for the following signs and symptoms that may indicate a serious problem.

Experiencing any of the following warning signs during the acute withdrawal stage indicates a need for immediate medical attention:

• Abdominal pains
• Hallucinations or increasing anxiety
• Psychosis
• Running a fever of more than 100.4 f
• Large changes in resting heart rate (up or down) or large changes in blood pressure
• Upper or Lower GI bleeding (blood in stool or in vomit)
• Neurological warning signs, such as a change in the responsiveness of your pupils to light
• Signs of seizure (read on below)
  

Warning Signs of Seizure

When detoxing from alcohol or sedative hypnotics, you need to be especially concerned about seizures. Two physical signs that warn of an increased risk of seizure are ankle clonus and heightened deep tendon reflex (when detoxing from alcohol, you are at greatest risk of seizure between 6 and 48 hours after abstinence or decreased consumption.)⁶

Ankle Clonus

Ankle clonus is an occurrence of multiple rhythmic contractions and relaxations of the ankle.

To test for ankle clonus, flex your foot upward as far as you can and then release it. Normally, your foot will return to a normal position. If you have ankle clonus, your foot will continue to jerk up and down through a serious of uncontrolled muscular contractions and relaxations.⁷

The presence of ankle clonus (sustained for more than 2 beats) indicates worsening central nervous system functioning and impairment of upper motor neurons - and this is often associated with the commencement of generalized seizure activity.⁸

Heightened Deep Tendon Reflex

When you tap on a tendon it contracts and causes a muscle movement - such as when you get tapped on the tendon of the kneecap when sitting, which causes your lower leg to kick out.⁸

Heightened or exaggerated deep tendon reflex is a warning sign of possible seizure.

Do not play around with the possibility of seizure, especially when they are easily prevented by the short term use of small doses of benzodiazepines. If you experience any warning signs of seizure - go to the ER.

Take-Home Message

• A detox program helps you stay safe and comfortable and preserves your dignity
• Detox should never end treatment. Consider it something that allows you to begin treatment
• You can find detox services in a range of settings, such as in your doctor’s office, through an outpatient program or residential rehab, in a specialized detox clinic or in a hospital
• There are 5 basic levels of detox, and it’s important to get matched to an appropriate level of care. You get matched to an appropriate level of care based on the results of your intake assessment
• Withdrawal can be dangerous. If you find yourself going through unsupported withdrawal symptoms, pay very close attention to warning signs of serious medical problems