1. The Detox Procedure:
Our Accelerated Detoxification procedure is designed to remove all of the narcotics that are attached to the patient’s brain receptors in the most comfortable, safe and speedy process as is possible. When people come in to detox they have a certain amount of narcotics that are attached to the receptors in their brain. Any detox procedure needs to assist the patient getting rid of all of those drugs so that the patient and the patient’s brain are completely drug-free. At that point the detox process is completed. If patients detoxify on their own without any assistance the drugs wash out of their brain in usually around five to ten days. This is extremely painful and most patients are unable to tolerate it on their own.
If Naltrexone is given at any time the Naltrexone medicine pushes all of the narcotics off the receptors and out of the brain in about twenty to sixty minutes. This is extremely uncomfortable, but can be successful. In the past I’ve performed around three hundred of these procedures, in a process called Ultra Rapid Detoxification (URD). This was so painful that it was necessary to put patients under general anesthesia and then keep them in the hospital for another twenty-four to forty-eight hours under extremely heavy medication. The process was successful, but we’ve found a much easier process, Accelerated Detoxification.
In Accelerated Detoxification we meet with the patient for a preoperative assessment and ask that they be in as much withdrawal as possible, usually around twelve to twenty-four hours. In this way, by the time we meet with them they’ve already started the detoxification and their brain is already preparing for a full detox both physically and psychologically. We then give them a combination of drugs, including Ultram, Valium and Clonidine. Ultram is like a narcotic that in high doses pushes some of the remaining narcotics out of the brain and off the receptors, similar to what Naltrexone does. However, it’s also a narcotic antagonist, which means that Ultram also relieves withdrawal symptoms. Sometimes the transition from the narcotics that the patient has been taking onto the Ultram can produce some withdrawal symptoms, although these are fairly short lived, lasting less than one to four hours. The Ultram lasts a long time, usually around four to five days and so it relieves the withdrawal symptoms until we do the actual Accelerated Detoxification procedure. Before the detox procedure we provide Valium to ease any withdrawal symptoms.
On the day of the detox the patient fasts and takes a large dose of oral Valium before arriving in the office. The oral Valium lasts a long time and provides good sedation throughout the whole detoxification procedure. We usually insert an IV so we can provide extra sedation throughout the course of the day. We then start introducing a narcotic antagonist, which starts pushing the patient’s narcotics out of the brain. Unlike an URD where this all happens at once we gradually introduce these drugs over a six to eight hour period, which is much easier for the patient to tolerate. By the end of the day the patient has received full doses of antagonists and we can insert the Naltrexone implant, knowing that they are fully detoxified and will not get any extra withdrawal symptoms once they leave the office.
2. Phases of Withdrawal – After working with many patients it is clear to me that there are three fairly distinct phases of withdrawal.
A. Acute Withdrawal – This is the process most people recognize as withdrawal. It is the most severe and lasts five to ten days. It is characterized by extreme agitation, cold chills, nausea and vomiting, diarrhea, abdominal and muscle pains. It usually peaks around the fourth day and then starts resolving. In an accelerated detoxification the acute phase is essentially completed within the first twenty-four hours.
B. Sub Acute withdrawal – This second stage is a withdrawal period that varies enormously from patient to patient. It lasts anywhere from one to eight weeks. It is the process of the brain healing and restoring its normal endorphins and neurochemicals. It is characterized essentially by fatigue during the day and insomnia at night. Initially these symptoms can be quite severe so that patients may not sleep for the first week or two, but gradually they resolve completely. There may be some mild agitation and anxiety. There may be depression, mood swings, and increased aches and pains.
C. Post Acute Withdrawal Syndrome – This third phase of withdrawal can last up to one to two years. This sounds formidable, but in reality the symptoms are so mild that they’re extremely tolerable and during this phase patients feel better than they have for years and so it’s really not a major problem. It is more of a situation that as patients look back they realize that by the third month they are a lot calmer, more relaxed and happier and self assured than they were one month earlier. At a year they have improved even more. Patients are even more calm and relaxed as things continue to get better and better, provided they work their program.
3. What To Expect
A. Before the accelerated detox – Before the detox we prepare patients, using the Ultram, as mentioned above. By the time patients come for their preop visit they need to get themselves into considerable withdrawal usually 12-24 hours of not using narcotics. We usually provide some Valium to help the first evening. At the preop visit they receive Ultram. After the Ultram there may be some increase in withdrawal symptoms since Ultram can actually push quite a lot of the narcotics out of the brain and precipitate some withdrawal. As mentioned, these usually only lasts one to four hours, but it can be quite unsettling. We frequently will ask patients to return later in the day if they’re not in sufficient withdrawal or we may give smaller doses of Ultram to try to decrease this. If this does happen it is not a bad thing because it indicates that quite a lot of the patients narcotics are being removed from the brain and this, of course assists in the detox process. Having the patients pretreated with some Valium seems to help with this. Following the Ultram patients usually feel fairly comfortable until their accelerated detox. They frequently sleep most of the day and the evening because the Ultram is relieving their withdrawal symptoms and they are now taking quite a lot of Valium. From our point of view this is a desirable state. If they can sleep through the first day or two, it is not a bad thing at all.
B. On the day of the detox – During the detox the patient is kept in our office for six to eight hours in a heavily sedated state. They are not completely asleep. They are maintained in a state where they’re able to get up to the bathroom if they need to, sometimes walk around the building, converse, but most of the time they’re sleepy. As the detox proceeds and as some of the medicine builds up they usually become somewhat confused. They will usually have a period of agitation where they become quite restless. This usually settles down by the time they are ready to be discharged. They usually have total amnesia for the whole day.
C. The first night – Following discharge from our office the patient is released to the care of their support person. They’re usually somewhat agitated and confused. They are unsteady on their feet and slurring their words. They often have some abnormal movements in terms of trying to pick things up off the floor. They will usually have total amnesia for the rest of the day. This is the most dangerous part of the detox procedure for the patient because in this state they cannot be relied on to make sensible decisions. It is the responsibility of the support person to make sure they are safe in terms of staying in the house, certainly not driving and being kept in a house where they can’t fall. This confusion and agitation gradually settles down. It is frequently completely gone by later that evening and almost always gone by the next morning. During this period there may be some mild nausea or even vomiting and there may be some diarrhea.
D. The week following the detox – During the next week the patient is in the sub acute withdrawal syndrome. They will frequently have fatigue during the day, which can sometimes be profound and prevent working. They will usually have insomnia so they will feel even more tired during the day. There may be some agitation. By now the confusion, diarrhea and nausea should be gone. Patients are usually eating and drinking quite normally. During this time the patient still requires some Valium and some other medicines, but it is best to use as little of this during the day, since they are already fatigued and use it at bedtime since that’s the time when they have trouble sleeping. We may need to prescribe other medicines to help with sleep during this period.
E. The month following detox – Over the course of the next month the patient’s energy and sleep returns to normal. There is gradual improvement during this period in all aspects.
4. Specific Withdrawal Problems That May Persist After the Detox
A. Nausea and vomiting – This is fairly rare, but may be present for the first eight to twelve hours. If it persists Phenergan suppositories can be quite useful.
B. Diarrhea – This is reasonably common to have one or two episodes the first night following the detox, but then it is almost always gone. If it persists the best treatment is Sandostatin injections. Fibercon may also be useful.
C. Muscle aches and pains – These are usually mild and resolve within the first eight to twenty-four hours.
D. Weakness – Patients may be weak and fatigued. They rapidly regain strength. No medicines are required. If patients are active on the days after the detox to their strength and energy levels seems to improve more quickly.
E. Restlessness – This can be a problem the first evening, but usually resolves over 6-12 hours. It responds somewhat to Valium and sometimes we add some Zyprexa. This is almost always completely gone by the next morning.
F. Insomnia – Can persist for quite sometime following the detox. The first week it is frequently pretty severe and problematic. We usually use a combination of Ambien, Valium and Zyprexa when it is a problem. Over time this resolves.
5. Long Term Recovery – It is important to remember that what we are essentially providing is a detoxification. Our long-term goal is obviously long-term recovery. Through some modern medical techniques we now have a fairly good idea of what causes cravings and relapse.
A. Craving and relapse – Modern PET scanners can actually take pictures of the brain and the pleasure center. These studies show that cravings are related to releases of Dopamine in the brain. Dopamine is the chemical that is found in the pleasure center and all drugs of abuse release cause secretion of extra amounts. When patients are in recovery and drug-free we find there are three specific things that release Dopamine in the brain, as if the patient had taken a small amount of drugs. This increase of Dopamine is associated with the patient feeling cravings for the drugs. These three things that release Dopamine in the brain and cause cravings are as follows:
1. Any mood altering drug – we know that it is absolutely essential for narcotic addicts to be completely abstinent from alcohol, pot, cocaine, amphetamines and other addictive drugs. All of these drugs release Dopamine into the brain and all of them will make the brain have cravings for heroin and other drugs. It is essential that all patients pay very close attention to this and be completely abstinent from all mood-altering drugs.
2. Things that were associated with the drug experience. Any environmental stimulus that was associated with the drug experience will actually release Dopamine in the brain. This means old friends, old places where people used to use, seeing drug paraphernalia, driving down the wrong street, getting a paycheck, seeing an ATM machine, hearing a song that was associated with using drugs, etc. All of these things will actually produce cravings in addicts. Eventually these will go away, but it may take years before these stimuli do not produce releases of dopamine in the brain. It is essential that all patients pay extremely close attention to this so that the brain has the best chance of staying drug-free.
3. Intense moods and emotions – Strong feelings, including sadness, grief, loneliness, depression, happiness, joy, and boredom can all release Dopamine in the brain and produce cravings for drugs. It is essential that patients work with therapists, and 12-step groups in order to keep themselves as even keeled as possible, especially in the early days of recovery.
6. Essentials for a Good Recovery Program
A. Naltrexone therapy – We believe that the cravings for narcotics are so intense and the length of time it takes the brain to heal is so long that most narcotic addicts will relapse back to drugs very quickly if they do not have Naltrexone therapy for additional support. We recommend Naltrexone therapy for twelve months. This prevents patients from relapsing back to narcotic use and gives patients a chance to start making changes in their life and building up a support system. We highly recommend at least two Naltrexone implants. We recommend more pellets if circumstances warrant closer support. Following implants, we recommend a two to four month period of taking oral Naltrexone in a supervised fashion, where the patient takes oral Naltrexone observed by a support person. It is best if the Naltrexone is crushed, mixed with water and then swallowed. If the patient is in recovery and is proceeding smoothly after six months or so, patients can usually take their own oral Naltrexone for the balance of the twelve months.
B. Twelve step groups – We cannot over emphasize the importance of 12-step groups. These programs provide support, philosophical material, and education to learn about and deal with all aspects of recovery. The groups take patients away from the usual using friends and usual using situations and put them into contact with people who are serious about their recovery. It may be that in your local area Alcoholics Anonymous (AA) is a stronger group than Narcotics Anonymous (NA). It may also be necessary to experiment with different groups to find a good strong group. Most locations have many, many groups and with only a small amount of experimentation you can easily find 12-step groups that are very supportive.
C. Substance abuse therapy – Patients have a lot to learn about living and staying drug-free. While support groups are helpful, it is our experience that professional therapists can add significantly, by being a little bit more educational and confrontive. They can also help patients to understand relapse and understand deeper psychological issues that may start becoming apparent during early recovery. Usually we recommend intensive outpatient programs, which meet in a group session three times a week. Depending on the circumstances individual therapy may be appropriate. If more intensive therapy is needed, then an inpatient stay can be helpful. Sometimes an extended care, halfway house is the best fit depending on how dysfunctional the patient’s lives have been.
D. Medical care – All patients need to follow up with physicians who are experienced in both substance abuse and mental health. This physician may be a psychiatrist, family practitioner or internist, provided that he/she is familiar with substance abuse, mental health, narcotic addiction and Naltrexone therapy. We can help provide lists of physicians who may be available in your area. This is particularly important since it is more and more apparent that after a patient gets drug-free a variety of mental health issues arise. It is very common that patients have periods of depression or anxiety. Sometimes there’s even bipolar illness, or other serious mental health problems that may require medications. As mentioned earlier if emotions are not kept on an even keel, then relapse is extremely common.
7. Final Notes – I believe that all substance abusers can achieve long term sobriety. Frequently, however, patients cannot or will not completely give 100% to their recovery program. Recovery from these drugs is the hardest thing that patients will ever do. If however, they’re able to get on top of it, the rest of their lives will be smooth sailing related to drug abuse. The more work they do in the early months the more likely they are to be successful. We almost never see someone relapse who completes ninety AA or NA meetings in ninety days. Most patients, unfortunately, are under the false illusion that they will be different and they don’t need to work quite as hard on their recovery. This is a mistake.
Our office will do everything we can to support your recovery. We’re available for questions or support at any time. We will attempt to contact you to document your recovery and to help in any way that we can./p>
If you have any questions or problems, please feel free to call us at 804/353-1230.
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