Withdrawal from drug and alcohol abuse may be dangerous and life-threatening. Two addiction experts discuss this important topic in a comprehensive South African guide on addiction.
Persons who regularly use drugs or alcohol in large volumes are usually either substance abusers or substance dependent.
Their bodies and brains have adapted in such a way that they develop a tolerance to the specific drug or alcohol. This means their bodies become so accustomed to the drug that they require increasing amounts of it to maintain their level of functioning. When a substance is then suddenly reduced or stopped, the body will struggle to cope. Such patients may then develop a withdrawal syndrome.
The DSM-IV-TR states that withdrawal from a substance refers to the development of a substance-specific syndrome due to the cessation or reduction in the substance use that has previously been heavy and prolonged. Such a substance specific syndrome should also cause significant distress or impairment in the level of functioning, in order to be clinically relevant. Furthermore, this syndrome should not be due to any other medical or mental condition.
Such a withdrawal syndrome can be unpleasant and may even be medically dangerous. It can certainly be a very frightening experience for patients and their families.
Fear of withdrawal
Many drug and alcohol users fear withdrawal symptoms and identify this as one of the reasons for continued use of drugs and alcohol. When a patient experiences withdrawal symptoms after stopping their drug or alcohol, they may find the experience so unpleasant that they simply believe it is not worth continuing with the withdrawal and subsequently restart their drug and alcohol use in order to reduce the unpleasant withdrawal symptoms. Their initial motivation and good intentions of achieving abstinence have been prematurely terminated.
Some withdrawal syndromes can also be extremely dangerous and even life threatening. These include the withdrawal from alcohol, sedative and hypnotic medication, opioids, cocaine and amphetamines. It is for this particular reason that a medically-trained healthcare professional must be involved in the assessment and withdrawal/detox phase of treatment. Fortunately, with modern treatment and supervision by an experienced and well-qualified healthcare professional, most withdrawals can be managed safely and effectively.
Detoxification refers to the process whereby a patient undergoes a medically supervised drug or alcohol withdrawal. Withdrawal from a drug or alcohol refers to the physical and mental symptoms that occur when the specific substance is reduced or stopped, and a detox is the process where the withdrawal symptoms are managed and treated by a suitably qualified healthcare professional.
As a general rule, some substances are more addictive than others. There are many reasons for this, but it is usually based on the pharmacology of the chemical compound involved. Certain substances have a rapid onset of action, are relatively short acting and are administered directly into the bloodstream. These substances are usually more addictive than others that have a slower onset of action, are longer acting and only reach the bloodstream late in their metabolism.
Intravenous use, smoking and nasal snorting of a chemical (such as intravenous heroin, smoking of heroin, snorting cocaine and cigarette smoking) rapidly reach the bloodstream and therefore the brain. Orally ingested substances (alcohol and pills, for example) take longer to be absorbed and are metabolised prior to reaching the blood and ultimately the brain.
Substances with a short duration of action are more likely to be addictive than those with a slower onset of action. For example, heroin and certain hypnotic medications are usually more addictive than the group of phenobarbiturate medication.
Lastly, drugs that have a short duration of effect, such as heroin and cocaine, and some hypnotic medications, are more likely to be addictive than longer acting substances, such as methadone.
Intravenous heroin is therefore highly addictive because it is injected straight into the bloodstream, from where it reaches the brain within seconds. It also has a rapid onset of action and a relatively short duration of action.
Other drugs such as the orally ingested, long-acting tablet chlordiazepoxide (a benzodiazepine), take much longer to have an effect and remain in the body for a longer period of time. Hence, they are generally less addictive – but still dangerous.
Drugs that potentially have a severe physical withdrawal syndrome can be dangerous and detox definitely requires supervision by a healthcare professional. These include alcohol, opioids, benzodiazepine medication, amphetamines and cocaine. Drugs that generally have minor physical withdrawal symptoms include dagga, LSD and PCP. Nicotine seems to fall between these two groups, as some people are readily able to stop smoking, while others seem to experience very unpleasant withdrawal symptoms when they stop.
What to expert
The path to abstinence invariably has to lead through a withdrawal phase and therefore an adequately supervised detox. There is simply no way to avoid this. If you or a family member wants to stop drugs or alcohol, you will have to go through a withdrawal period. The only exception would be users of drugs that have very limited or even no withdrawal symptoms (LSD, PCP and dagga, for example).
It is therefore imperative that every user and their family think about withdrawal and detoxing very early in their help-seeking process. Withdrawal and detoxing should be discussed and evaluated as early as during the assessment phase and the preparation phase.
Most withdrawal symptoms usually begin shortly after the substance has been reduced or stopped, and onset can be within hours of the last drug or alcohol ingestion. For example, an intravenous heroin user may experience withdrawals up to three or four times a day, and will therefore need to inject themselves with heroin that many times per day in order to stop withdrawal symptoms. An alcohol dependent person may experience early withdrawal symptoms very shortly after stopping drinking. This may even occur in the morning after a heavy alcohol binge. Depending on the specific drugs involved, most withdrawal symptoms can last for a few days and some may even last for a number of weeks or months.
What will happen to me?
The withdrawal syndrome usually presents with a number of unpleasant physical and mental symptoms. As mentioned before, this could be dangerous and even life threatening.
It is therefore best to discuss any planned withdrawal with your healthcare professional. Usually your local general practitioner is best suited to this. If they were to realise that the situation was medically or mentally risky, they would refer you to the relevant specialists and services.
It is very important to be completely honest with your healthcare professional. Specifically, you have to be open and honest about the exact drug that you have consumed, the volume and frequency of use, previous treatments and their outcomes, as well as the time when the drug was used for the last time.
Doctors need to know this information in order to make the best and safest treatment decisions. It is no use, and possibly even dangerous, to lie about this information by underreporting, because this will lead your doctor to undertreat, and thus the experience of withdrawal will be very unpleasant and potentially dangerous.
Similarly, it is not a good idea to overreport your drug and alcohol consumption either, hoping to get more medication, because you may be overtreated, which has its own set of potentially dangerous consequences.
Speaking to others
Another good idea is to learn as much as possible by speaking to other people who have managed to remain abstinent and are in recovery. It is also helpful to read widely about your specific drug, its withdrawal and treatments. An informed patient is a patient who can take responsibility for and ownership of their recovery. I often suggest that my patients and their families should not believe everything that they hear on the grapevine. Most drug-using friends simply spread myths, urban legends and half-truths and engage in scaremongering. Most planned withdrawals can be managed through a safe and effective detox regime.
Once you are ready, make the commitment and implement your decision.
Tell your healthcare professional and your family. Ask them for support and assistance. Your GP may likely suggest an inpatient or outpatient treatment course, certain medications and specific follow-up arrangements.
Prior to detox, you should have specific plans in place and be ready for the post-detox period, that is rehabilitation.
Substance-dependent persons and those who abuse drugs and alcohol are likely to require a period of rehabilitation in order to learn an abstinence-based lifestyle.
How can I help myself before and during detox?
There are numerous things that you and your family can do prior to, and during a detox.
• Inform yourself and your family about your intentions, plans and risk factors.
• Prepare yourself mentally and physically for a detox and the rehabilitation process.
• Go and see a healthcare professional for a full assessment of your medical and mental health status.
• Take ownership of and responsibility for your drug and alcohol use.
• Remain motivated throughout this process, even if the situation gets uncomfortable and unpleasant.
• Nurture and support your network of friends, family, church and work colleagues.
• Ensure optimal nutrition and hydration, by eating healthily and adequately.
• Optimise any medical conditions that you suffer from, including blood pressure problems, diabetes, epilepsy, or any other medical problems.
• If religion and faith are important to you, then practise and nurture this by praying and meditating.
• During the detox, avoid specific commitments and responsibilities, such as going to work and taking on specific
roles within your family.
• Make sure that you remain safe by being well informed about warning signs, having a telephone handy, making regular contact with family, friends and healthcare professionals, closely monitoring yourself throughout the process, and being aware of the high-risk complications associated with your drug and alcohol use. (Generally, it is not a good idea to do a detox at home if you live alone.)
• Monitor your own progress. It is always a good idea to agree with your healthcare professional that you will diarise and record certain aspects of your withdrawal, such as your pulse rate, your anxiety or mood levels, your respiration rate, or even your blood pressure.
• Take the medication exactly as it is prescribed by your doctor. Again, it is best to diarise and chart your medication use, and then to show this to your doctor at your regular visits. (If possible, have a loved one supervise the administration of your medications.)
• Visit your healthcare professional regularly. Your GP is part of your support network and it is important that he or she be very well informed and aware of what you are doing and how you are doing it. Do not skip appointments simply to save money, as you may end up with high-risk medical complications that are certainly going to cost you more and may even cause damage to your body and brain.
When should I seek help?
It is very important that nobody should undergo a withdrawal or detox without a comprehensive multidisciplinary assessment, which has to include a medical assessment by a healthcare professional, such as your GP. It is therefore always best to make contact with your GP in advance to plan and initiate the correct treatment. You should also make follow-up arrangements throughout the withdrawal and detox phase. Do not self-medicate with either your own or somebody else’s medication. As mentioned before, some drugs are more risky than others, and you, your family as well as your healthcare professional should also be aware of potentially higher risk situations. Such higher risks may occur in the following cases:
• Young and elderly patients.
• Patients who use more than one drug, such as combinations of alcohol and drugs, or multiple illicit drugs with or without prescription or over-the-counter medications concurrently.
• Previous treatment episodes that have ended with a relapse and an inability to remain abstinent.
• Associated mental health problems, such as depression, anxiety, psychosis, mania or suicide attempts.
• Associated medical illnesses, such as diabetes, high blood pressure, epilepsy, heart and lung problems.
• Pregnant women.
• Patients who are isolated or have a poor support network, such as the homeless and those without family nearby.
• Malnourished or neglected patients.
• Patients with a history of previous substance associated complications, which could include jaundice and liver failure, seizures and convulsions, confusional states, hallucinations, fever and dehydration, vomiting and a loss of consciousness.
All of the above categories of clients should be in close contact with their healthcare professional and should probably be admitted to a general medical hospital for their detox. Lower risk groups of patients can possibly be managed by the healthcare professional in the outpatient setting. Such a decision depends on many factors, and should only be made by the healthcare professional after a detailed assessment.
This is an edited extract from The End of Addiction by Dr Volker Hitzeroth and Dr Liezl Kramer. Order your copy here.
(Health24, June 2010)