By: Bonnie Nolan, PhD, Addiction Services Coordinator
Woodbridge Township Department of Health & Human Services
“Detox” is another of the many curious new words that have become part of our lexicon in the context of the opioid epidemic. Debate rages, even in the clinical community, about the need for medically-monitored detoxification prior to treatment for opioid use disorder. We have known for centuries that withdrawal from alcohol (and more recent anxiolytic benzodiazepine drugs like Xanax, Valium, Ativan, Klonopin, aka “benzos”) can produce life-threatening seizures and therefore require medical monitoring. The data on opioid withdrawal is less clear.
As the nation responds to the opioid epidemic in a more evidence-based fashion, it becomes necessary to examine the consequences of “white-knuckling” detox, that is, coming off the drug of choice without medical assistance. While it is difficult to get exact figures on these rates, as they are obviously not being reported to agencies like the CDC, we know that withdrawal is an incredibly painful and frightening experience to a person who is addicted to opioids like prescription painkillers and heroin. In cases where there is advanced addiction, symptoms can be so severe that an addicted person is awakened at night by illness even after using just before going to sleep. In other words, symptoms begin almost immediately after the drug effects peak. These symptoms include nausea, abdominal pain, nervousness, agitation, muscle spasms, sweating, shaking, diarrhea and intense craving. Subsequent use is thus referred to as relapse.
Relapse rates among people with opioid use disorders are high even with medication-assisted detox if no subsequent treatment is provided. There are many reasons for this, but one important reason is that withdrawal symptoms can persist well beyond the 1- 5 days of acute symptoms. Post-acute withdrawal symptoms include anxiety, drug craving and anhedonia (inability to feel joy). This can lead to major depressive disorder and increased risk for suicide. While not all treatment is created equal, evidence-based strategies such as Cognitive-Behavioral Therapy (CBT) and medication-assisted treatment (MAT) and others are known to significantly reduce relapse rates. Since most licensed facilities require medication-assisted detox with medical clearance prior to admission to an inpatient treatment program, persons addicted to opioids should seek medical help.
Unfortunately, medically monitored detox services are difficult for many to attain. Because withdrawal from heroin was not traditionally considered life threatening, hospitals have not been required to treat withdrawal symptoms, and insurers have not been required to pay for it. This is slowly changing with regard to private insurers; they are now generally required to pay for detox when it is deemed medically necessary. However, the age group most affected by the opioid epidemic is between the ages of 26-44, and these patients typically have Medicaid or no insurance. The only option covered by Medicaid is hospital-based detox, and there are about 7 of these facilities in the state of New Jersey. More hospital-based detox facilities would certainly go a long way to stemming the tide of opioid overdose deaths.
