Columbia University Medical Center
Ranked #1 in Psychiatry
U.S. News & World Report
Ranked #1 in Research Funding
National Institutes of Health
NewYork-Presbyterian Hospital The University Hospital of Columbia and Cornell

Ask the Experts

Question:

How do I know if I need drug or alcohol detoxification?

Answered by: Eric Collins

Detoxification, also referred to sometimes as medically-assisted withdrawal, is a process that helps a person safely get off a drug (including alcohol and some prescription medications) on which they have become physically dependent.

Physical dependence is present when someone experiences a withdrawal syndrome upon stopping or suddenly taking much less of the drug. Each drug or class of drugs with similar effects produces a different kind of withdrawal syndrome, some of which are potentially life-threatening.

The withdrawal syndrome is the physiologic manifestation of nervous system changes unmasked when the drug is no longer in the body. Specific withdrawal symptoms are frequently in the opposite direction of the immediate effects of the drug (e.g., anxiety is a prominent withdrawal symptom in people dependent on anxiety-reducing medications). Patients with tolerance (resistance) to a drug's effects will usually have withdrawal.

There are four important questions to answer in deciding if someone needs detoxification (with medical assistance).

First, is the person physically dependent on the medication (i.e., do they experience a characteristic withdrawal syndrome when the medication is stopped)? If not, there is no need for detoxification.

Second, should the patient be taken off the class of medications, or would it be better to switch the patient to a maintenance treatment? This criterion applies to patients dependent on opioids, many of whom can only achieve abstinence from addictive opioid use when they are maintained on a long acting opioid medication (methadone or buprenorphine). If they are to be maintained on methadone or buprenorphine, they will be transitioned to the maintenance medication rather than detoxified.

Third, is the withdrawal syndrome life-threatening? Regular smokers of more than 5 cigarettes daily will virtually all have nicotine withdrawal, but none will need medical assistance in a hospital, because nicotine withdrawal, while unpleasant, is not life-threatening. Regular heavy drinkers and individuals dependent on sedative medications, however, may experience life-threatening withdrawal and do require detoxification.

Fourth, is the withdrawal syndrome so uncomfortable that it is virtually impossible for someone to stop using the drug without help? This is very frequently the case for opioids (heroin and prescription pain medications), for which the withdrawal syndrome is not life-threatening but extraordinarily uncomfortable. It is rarely the case for other drugs.

The decision about detoxification should be made in conjunction with a specialist in addictions. The choices of setting (inpatient vs. outpatient) and specific approach to detoxification require experience and expertise in managing addiction illness.

In general, individuals dependent on alcohol, sedative medications (e.g., Valium, Xanax, Ativan, Klonopin, phenobarbital and other barbiturates, and most prescription sleep medications) and opioids (heroin, oxycodone, Vicodin, Percocet, morphine, Dilaudid, and others) will require detoxification. But even regular or daily, high-dose users of marijuana, cocaine, prescription stimulants (amphetamines, Ritalin, and others), hallucinogens, or ecstasy will not require detoxification, even though they might experience unpleasant side effects if they stop the drugs abruptly.