Summer House
Drug and Alcohol Detoxification Jul 09, 2008
The body’s reaction to the removal of a substance it has become dependent on is called withdrawal. Withdrawal causes craving for more of the substance being removed. The period of time when the body is trying to overcome its addiction is called detoxifica-tion (detox). Detox is the first step in overcoming a substance addiction such as drugs or alcohol. Detox is a pertinent step for the patient is to be successfully rehabilitated.
Opiate drugs such as heroin and methadone, and prescription medications including Hydrocodone, Oxycontin, Xanax, Vicodin and Lortab, require medical detox supervision. There are however, other illegal drugs such as marijuana, crystal methamphetamine, and cocaine that do not require medical detox. Since there is psychological dependence associated with these drugs, it would be wise to complete a period of stabilization. The process of drug detox requires the patient to be closely monitored by keeping vital signs, giving support and administering medications if needed. There are numerous withdrawal symptoms or side effects when a patient stops or dramatically reduces drugs after heavy or prolonged use. Those side effects include: sweating, shaking, headaches, drug cravings, nausea, vomiting, abdominal cramps, diarrhea, sleeplessness, confusion, agitation, depression, anxiety, and other behavioral changes.
There are two commonly used drugs to enable the patient to feel relief from these symptoms. First, Klonepin, which reduces physical symptoms, and Buprenophex, which is an anticonvulsant. These drugs must also be monitored as cessation produces withdrawal symptoms. Generally, the time period for drug detox is three to seven days under medically monitored supervision.
Alcohol detox, like drug detox, is usually accomplished in an inpatient medical facility. Duncan Raistrick identifies the key to a successful, planned detoxification is preparation. Raistrick goes further to detail that the first job of therapy is to bring the patient to a point of readiness to change their drinking behavior. Second, patients need to be given accurate information about what to expect during detoxification.
There are two withdrawal categories: minor, meaning early withdrawal and major, meaning late. The severity of withdrawal depends greatly on the duration of alcohol used. Alcohol Withdrawal Syndrome (AWS) falls into three main categories: central nervous system (CNS) excitation, excessive function of the autonomic nervous system (ANS), and cognitive dysfunction.5 Richard Saitz, M.D., M.P.H., states, since alcohol enhances gamma-aminobutyric acid’s (GABA) inhibitory effects on signal-receiving neurons, neuronal activity is lowered. This lowering leads to an increase in excitatory glutamate receptors. Tolerance occurs as GABA receptors become less responsive to neurotransmitters, which in turn requires more alcohol to produce the same inhibitory effect. During detox, the GABA is ineffective and unable to suppress the excitatory glutamate receptors. Detox is intended to relieve physical symptoms such as: shaking or tremors, headaches, vomiting, sweating, restlessness, loss of appetite, sleeplessness, Delirium Tremens (DT’s), hyperactivity, and convulsions. Alcohol detox medications are similar to drug detox medications: Buprenophex, certain benzodiazepines and anticonvulsant medications. Alcohol detox completion can take from three to fourteen days.
Norman S. Miller notes that medical management of alcohol and drug withdrawal during detoxification often is not sufficient to produce sustained abstinence from recurrent use. Therefore, further addiction treatments are needed to prevent relapse to alcohol and drug use following treatment of withdrawal.
In conclusion, drug and alcohol detoxification can effectively prepare the addicted abuser for rehabilitation and treatment.
Some physicians believe the withdrawal phase is related closely to the drug addiction – the worse the withdrawal, the more likely the continued use of the chemical to prevent withdrawal. Several factors are key to successful detoxification.
1. Acknowledge that there is a problem and decide to do something about it.
2. Get rid of all the drugs and paraphernalia.
3. Drop friends and associates that are tied to our drug problem.
4. Seek and accept spousal support, or support from friends, or relatives.
5. Prepare for symptoms with the support of a professional.
6. If tranquilizer drugs are needed for a few days or longer, they must be handled sensitively, as one addiction can easily replace another.
Alcoholism Treatment Programs and Interventions Jul 09, 2008
Close to a million Americans are treated for alcoholism on a daily basis. For the past 3 decades, the majority of treatments have been empirical and the success of the treatments has never been verified by clinical trials. The numerous methods developed in the treatment of alcohol addiction include the use of medications, psychological, social, behavioral methods and self help groups- all designed to help achieve abstinence from alcohol.
The initial approaches to alcohol treatment were all based on self help and over the years the 12-step self help program has become the gold standard. Other treatments include brief interventions by visiting the primary care physician or trained nurses. Behavioral and psychosocial support therapies have evolved over years and generally involve long term therapy. Over the last 2 decades, motivational enhancement therapy and involvement of the non-drinking spouse have evolved and produced good results.
Of course, over the past 4 decades, pharmacological approaches to alcoholism treatment have made some progress, but the ideal drug still remains to be discovered.
Alcoholism Treatment
The majority of individuals with alcohol dependence initially always deny that they have a problem and are reluctant to undergo therapy. Agreeing to undergo alcohol treatment usually occurs after the individual encounters health, family, employment or legal problems. Depending on the situation of the individual, various treatments are available to help with alcohol dependence. The initial part of the treatment involves evaluation, a brief intervention and either an in/outpatient program or counseling.
Principles of Alcohol Dependence Treatment
Before alcohol treatment can begin, one has to determine if the individual is alcohol dependent. For some who drink socially and are in control over their drinking, treatment may simply require reduction of drinking<. For those who have no control over their drinking, the best treatment is abstinence.
To maintain abstinence, the best approach is to be included with alcohol abuse therapists. These specialists can help develop specific-tailor made treatment plans, which may include objectives, behavioral modification skills, use of self-help manuals, counseling and follow-up care at a treatment center.
Non Drug Residential treatment programs
There are numerous non-drug residential alcoholism treatment institutions and include therapy to maintain abstinence, individual and group therapy, participation in alcoholism support groups (such as Alcoholics Anonymous), educational seminars, spousal involvement, work assignments, physical and non physical activity therapy. Most of these residential programs have professional counselors and staff involved in the treatment of alcohol dependence.
All individuals undergo a complete physical and medical assessment prior to therapy. The essence of all residential programs is to commence detoxification and treatment of withdrawal symptoms that may occur. Hard-hitting psychological counseling and psychiatric treatment is offered to individuals, couples and their families. The principal emphasis of all residential programs is on recognition of the problem and motivation for abstinence. Individuals who are unable to fulfill this basic criteria usually do not succeed with therapy.
Psychological, Behavioural and Social therapy
Numerous behavioral approaches to alcohol dependence treatment include psychological therapy. The primary component of these therapies is motivational enhancement therapy. This therapy is designed to help the individual become more responsible and develop a change in his lifestyle.
Various forms of counseling are available and may involve cognitive behavior therapy to help cope with distorted/abnormal thoughts and help develop a sense of control over these thoughts and feelings.
The majority of pychological therapies often involve the non-alcoholic spouse as most studies show that couple participation increases the likelihood of abstinence from alcohol. Behavioral –marital therapy is a combination of an approach to drinking treatment while strengthening the marital relationship through sharing, teaching and communication skills
Self-Help Programs
The most common self help group in the treatment of alcohol dependence is Alcoholics Anonymous (AA). This is one of the most common and easily available group in any community.
Alcoholics usually get involved with AA before seeking professional help, as a part of it, or as aftercare following professional treatment. Although anecdotal data on the success of AA are plentiful, results indicate that inpatient treatment, a combination of professional treatment and AA, will achieve better results for more people than AA alone. The reason why AA has been beneficial as a treatment for alcohol addiction includes isolating the individual from his social network of alcoholic friends, providing psychological/social support, teaching coping skills and structured behavior treatment.
Physician intervention
Some indivuals receive counseling from primary care physicians and trained nursing professionals. This consists of numerous office visits and counseling. The majority of these brief interventions help those with acute alcoholic crises. Following the brief intervention, all individuals are recommended to enter specialized treatment programs if the alcohol consumption continues.
Drug Treatments
Disulfiram (Antabuse) is an alcohol-sensitizing drug which has been around for at least 40 years. It was the first drug used for aversion therapy. It provides a strong deterrent to alcohol. It is not a cure and does not decrease the craving for alcohol. If taken before an alcoholic drink, it causes a severe reaction that includes nausea, vomiting, facial flushing and headaches. The drug is rarely used today as the severe reaction is not tolerated and most alcoholics are reluctant to take it.
Naltrexone (ReVia), is an antagonist of morphine and has been found to decrease the urge to drink. As is the case with all addiction disorders, however, naltrexone is only effective if taken on a regular basis.
Acamprosate (Campral) is a drug that decreases alcohol cravings and helps maintain abstinence from alcohol. Unlike disulfiram, naltrexone and acamprosate have fewer side effects and do not produce serious nausea and vomiting if alcohol is consumed.
Recently, the Food and Drug Administration (FDA) approved the first injectable drug to treat alcohol dependence. Vivitrol, a drug similar to naltrexone is administered by an intramuscular injection in the buttocks monthly. It has been shown to decrease the urge to drink by blocking neuro receptors/transmitters that may be coupled with alcohol dependence. Vivitrol has no effect on the withdrawal symptoms due to alcohol. The drug is recommended for use by alcoholics who are undergoing psychosocial therapy and have not consumed any alcohol in the recent past. The drug is also available as a pill, but it has been found that the injectable formulation is easier for individuals recovering from alcohol dependence and only has to be administered once a month.
Even though some drugs may reduce alcohol drinking, it is highly recommended that individuals enter in aftercare programs and prop up groups to help prevent relapse and encourage motivational behavioral and life style changes.
Conclusion
Research supports the idea of using drugs as an adjunct to the psychosocial/behavioral therapy for alcohol abuse and dependence. However, additional clinical trials are needed to identify those patients who will most likely benefit from such an approach, to determine the most appropriate medications for different individuals, to develop optimal dosing formulas, and to develop strategies for improving patient compliance with medication protocols.
With continued research on the effect of alcohol on the brain and behavior, hopefully this will lead to the magic pill. Drugs to decrease alcohol craving are around but specific medications are still missing. In the meantime, the combination of drug therapy and the use of behavioral therapies are the best hope for recovery of the individual -and the lives of loved ones-who suffer from alcohol abuse and dependence.
Washington Post – When it comes to treatment, the experts think alcoholism needs to catch up to depression.
Three decades ago, long before the dawn of the Prozac Era, depression was a disease rarely treated in its mild form, reluctantly treated with drugs and usually treated by experts only. Today, signs of depression are actively sought, drugs are prescribed early and often, and most cases are handled by nonpsychiatrists.
With alcohol abuse, however, most physicians don’t go looking for trouble and don’t recognize it until it’s breathing in their face. Over-drinking patients often don’t think of looking for help even if they know they are heading in the wrong direction. And society as a rule looks at alcohol treatment as a last-chance, 90-degree corner taken only at high speed.
Simplify screening
All this will change if American physicians adopt the new guidelines for "Helping Patients Who Drink Too Much" promulgated by the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health.
The idea is to simplify the screening for excessive alcohol use in general medical practice and to convince clinicians and patients that early intervention for drinking that hasn’t yet wreaked havoc is both possible and useful.
"We’re trying to increase the accessibility and attractiveness of treatment to a much broader spectrum of people," said Mark L. Willenbring, a psychiatrist who directs the Division of Treatment and Recovery Research at NIAAA.
Those especially targeted in the guidelines are heavy drinkers who are not yet physically dependent on alcohol but are at risk for becoming so.
"We know that that group responds very, very well to what we call facilitated self-change and brief motivational counseling. We could make that very widely available without much cost," Willenbring said.
A big part of the new strategy is to make primary care physicians — people without specialized training in addiction medicine — think about alcohol abuse the way many now think about depression, anxiety and obsessive-compulsive disorder. Which is to say, they need to think of it as something common, diagnosable and within their capacity to treat. The guidelines make this easy: The screening tool for alcohol problems consists of a single question. For men: How many days in the past year have you had five or more drinks? For women: How many days in the past year have you had four or more drinks?
"Most doctors don’t know how to make the diagnosis and don’t really try to do anything about it until it is so easy to diagnose that all you have to do is glance at the patient," said Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania who has been treating alcoholics for 38 years.
"It used to be said that you can’t treat somebody until they are down and out. But when they are down and out, they are really hard to treat," O’Brien said.
Willenbring concurs.
"I think there is a belief that people with more moderate levels of dependence don’t know they have a problem. I think they do. But they don’t think rehab is the model of treatment for them — and I don’t, either."
The sort of therapy both advocate does not involve magic bullets or easy answers or effortless behavior change. But it does enlist pills that help a little, quite a bit of talk and lots of self-discipline.
And what does it get a person?
Perhaps not surprisingly, there’s evidence that getting control of a drinking problem early can improve one’s health, completely apart from the social, psychological and familial benefits it brings.
Looking at death rates
A study published two years ago looked at the experience of 628 men and women who entered alcoholism treatment (either in residential rehab or as outpatients) in their mid-30s and were followed for 16 years.
Over that period, 121 died, or 1.2 percent a year. The average age of death was 48. But the chance of dying was significantly lower in people who after the first year were abstinent or had no drinking-related problems or symptoms.
So how successful is treatment, or at least how successful has it been?
Researchers in 2000 analyzed seven studies, one going back to the late 1970s, in which more than 8,000 people were treated for alcoholism in various ways, including with drugs. After a single course of treatment, one-fourth were abstinent for at least a year and one-tenth dramatically decreased their drinking. The rest, about two-thirds of the subjects, drank less often and in quantities averaging less than half of what they consumed before treatment. Mortality in the first year was 1.5 percent.
Some of those patients had a four-week stay in "rehab," but most did not. A long treatment-center admission as the optimal strategy to stop a serious drinking problem is much more the model of the 1980s than the 2000s. The newer one emphasizes outpatient treatment — occasionally after a brief hospital stay for acute detoxification, if necessary — with care provided by non-specialists in many cases.
How often contemporary treatment succeeds was also explored in a complicated clinical trial of about 1,400 alcohol-dependent men and women, average age 44 and consuming 12 drinks a day, that was published in the Journal of the American Medical Association in 2006.
The researchers randomly assigned the patients to nine groups. Four of the groups got nine sessions, conducted by a doctor or nurse and lasting at least 20 minutes, that reviewed the health consequences of excessive drinking, encouraged abstinence and attendance at Alcoholics Anonymous meetings, and urged adherence to the study medicines. Four of the groups also got intensive counseling by alcohol-addiction experts — up to 20 hour-long sessions.
Drug therapy
Some of the patients were assigned to take a drug for three months: either naltrexone, which blocks opiate receptors in the brain that are involved in alcohol’s "reward pathways," or acamprosate, which works through so-called GABA receptors to decrease the anxiety and restlessness that can come with abstinence. Some got placebo pills.
A year later, there were no big differences among any of the groups, although there were some interesting small ones. (This was true even with what the researchers considered the placebo group, the people who received specialized alcohol counseling but no time with a physician and no pills.)
People who met regularly with a doctor or nurse and then got either naltrexone or the intensive counseling did equally well; about 66 percent were abstinent. People who had those sessions and got placebos did less well; 59 percent were abstinent. Those who got intensive counseling but no pills, neither active ones nor placebos, had an intermediate outcome, with 62 percent abstinent.
Unlike some other studies, this one showed no benefit from acamprosate. But that may not be the last word.
Interesting findings
A clinical trial not yet published showed the drug worked only when started during a period of abstinence, not while a person was still drinking. And last month researchers reported more evidence that GABA receptors play a role in alcohol addiction. Laboratory rats that got the drug gabapentin, which enhances the action of GABA, drank less — but only if they were already chronically exposed to alcohol. Those that used alcohol only occasionally did not show such an effect, suggesting the pre-existing state was crucial to the response.
Abstinence, in almost all practitioners’ minds, is always the goal. But its absence doesn’t signal abject failure.
"It is a fiction that the typical change process is a sudden transformation," Willenbring said. "The more common is a change process that lasts years and is characterized by lengthening periods of sobriety and shorter relapses until they are gone."
In that way, alcohol abuse is like depression. In another way, too.
"Recovery from depression requires effort. The same is true for alcohol dependence," he said.
And in both cases, he thinks they’re really worth the effort.
The two drugs, along with a dummy pill called a placebo, were tested for 22 months among 126 patients in Malaysia who had emerged from a detoxification and counselling programme, it said.
Buprenorphine, which is marketed as Temgesic or Buprenex, was twice as effective as naltrexone (branded as Revia, Depade or Vivitrol) and the placebo in terms of days of abstinence from heroin and a full-fledged relapse to the narcotic.
Indeed, buprenorphine proved to be so superior that the trial was halted early, as it would have been unethical to continue it to its scheduled end.
The study, led by Yale University’s Richard Schottenfeld, gives support for placing buprenorphine alongside methadone, and both of them over naltrexone, as pharmacological treatments for helping addicts stay off heroin.
The three drugs belong to a class called opioid antagonists.
These treatments are increasingly used to help ease heroin dependence but remain prohibited in some countries, amid suspicions that they are liable to be abused or simply substitute one addiction for another.
The study is important because it gives the first assessment of the relative effectiveness of two of the opioid antagonists.
Heroin and other illicit opiates were once a problem mainly confined to developed countries, but in the past few decades have spread to developing economies and nations of the former Soviet bloc.
China, India, Indonesia, Iran, Malaysia, Pakistan and Russia are among the countries where expansion of heroin use has risen fastest, according to a 2004 World Health Organisation (WHO) paper.
An evaluation of alcoholism treatment suggests more ways to define success than strictly total abstinence. The method may help provide some changes to traditional approaches, the results of a case study suggest. "It may be argued that subjects who remain abstinent [from alcohol] during treatment are the most successful because psychosocial functioning and physical health depend on sobriety," say study authors Sue-Jane Wang, Ph.D., and Celia Winchell, M.D., and colleagues from the U.S. Food and Drug Administration in Rockville, Md. "However, other patterns of drinking are very common during treatment and many analytic approaches fail to make a distinction among the patterns." "For example, traditional research methods often don’t distinguish between a person who drinks only once a week during a 12-week trial and one who abstains for the first 10 weeks but spends the last two weeks intoxicated, according to the study.
These summary measures fail to capture the full complexity of the drinking pattern over time," the researchers say. The authors said, "There has been a great deal of contention on whether the effects of alcoholism treatment should be evaluated solely against the criterion of abstinence. The clinical community is still searching for a better description of what constitutes effectiveness in alcoholism treatment trials. More informative statistical analysis methods are necessary to arrive at meaningful evidence."
According to a Center for the Advancement of Health report, "Wang and colleagues tested a research tool called the ‘multiple failure time’ approach that asks more nuanced questions than traditional approaches, including: ‘Does the treatment reduce the rate of relapse to heavy drinking?’ They used this approach to re-examine a study that found weakly statistically significant evidence that an alcoholism treatment drug called naltrexone was effective." By taking into account both the time and the frequency of the study participants’ drinking episodes, the researchers noted two things that were overlooked in the first analysis: The risk of having any drinking episodes and any heavy drinking episodes was significantly lower in the group treated with naltrexone rather than a placebo, the report said. Source: The study results were published in the March 2003 journal Alcoholism: Clinical and Experimental Research.