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Despite the promise of 21st century scientific advances, chemical dependency continues to challenge and strain individual health, families, communities’ safety, and the economy at large. “Drugs cost America 52,000 deaths a year and $110 billion. If left unchecked, illegal drugs will cost the United States 500,000 deaths and a trillion dollars over the next decade” (McCaffrey, 2000). As the cost of chemical dependency balloons, our society will need to pay more attention to the prevention and treatment of addictions.

Pharmaceutical and medical interventions comprise a core standard of addiction treatment. This article discusses three such recovery tools used today to tame and manage addictions. Addiction counselors need to learn the mechanics of chemical detoxification, pharmaceutical medical interventions, and drug testing. Although addiction counselors cannot prescribe medications or directly facilitate interventions that involve drug testing, clients receive the most efficacious treatment from addiction counselors who understand the protocols and benefits of these treatment options.

Detoxification
Merriam-Webster’s Dictionary defines “detoxify” as (1a) to remove a poison or toxin or the effect of such from; (1b) to render [a harmful substance] harmless; (2) to free [as a drug user or an alcoholic] from an intoxicating or an addictive substance in the body or from dependence on or addiction to such a substance. Scientific advancements offer three modes of detoxification, depending on the client’s level of dependency. In traditional detoxification, a client may enter into a 5- to 15-day medically supervised detoxification program. Rapid chemical detoxification is achieved by placing the client in a comatose state while moving through phases of withdrawal. In outpatient detoxification programs, the client participates in medical intervention, but goes home each day.

Clients who are psychologically and physically addicted to chemicals will need to undergo detoxification as a component of therapy — the question is, how do we know which detox strategy is right for the client? By working in consultation with a physician who specializes in detoxification, the addiction counselor can provide appropriate, efficacious treatment for the client. Science has radically improved detoxification techniques over the last two decades. The implication for addiction counseling is that by developing relationships with detox specialists, the addiction counselor can facilitate referrals that promote continuity of care and reinforce trust and motivation by including the counselor as a member of what becomes a multidisciplinary treatment team. This consultation is essential if assessment suggests rapid detox or outpatient detox as the treatment option.

Regardless of the detoxification model used, one common construct that an addiction counselor must be aware of is drug withdrawal. The DSM-IV-TR definition of withdrawal can be summarized as significant physical, mental, or social distress or impairment caused when heavy or long-term substance use is abruptly reduced or stopped. Drug withdrawal complicates detoxification because of the number of variables at play (e.g., frequency, duration, intensity, kind of drug, and absence time without drug will impact how dramatic withdrawal symptoms can be — from mild to life-threatening). Another challenge of withdrawal is the presence of cravings, the habitual desire for the substances that created drug euphoria. In this cycle, the unconscious brain tells the client to get rid of these withdrawal symptoms quickly by just taking the drug. As a result, the client in withdrawal is challenged by both physical symptoms (e.g., alcohol withdrawal can create tremors) and the psychological (e.g., internal dialogue says: to feel good, use the drug). Narconon of Southern California, Inc. provides an excellent overview of withdrawal for the various drugs addiction counselors face most often; this resource is online at http://www.addictionwithdrawal.com/.

Five-step detoxification decision-making process
As with all phases of counseling along the treatment continuum, motivation is an essential component of the detoxification process (Prochaska & DiClemente, 1982). Motivational interviewing (MI) strategies (Miller & Rollnick, 1991) are helpful for assisting clients unsure of the value of detoxification to discover motivation from within themselves (for more information about MI, see page 36). The following five-step model provides the addiction counselor with a frame of reference in aligning a client with a detoxification program:

Step 1. Assess to determine if the client is physically or psychologically dependent as per the DSM-IV-TR. An addiction counselor can reference a drug chart (e-mail editor@counselormagazine to request a copy of the drug chart) to determine the medical risks for various drugs. A quick online resource developed by the Addiction Science Network can be found at www.addictionscience.net/ASNclass.htm. Clients who meet this criterion need to be assessed by a physician for medical risk.

Step 2. Review and be clear about the physical and psychological withdrawal factors for the particular drug(s) in question. Also determine potential client resources (e.g., family, social supports, finances, living arrangements).

Step 3. Educate the client about potential withdrawal and associated health risks. Discuss how cravings can fuel an immediate relapse if not addressed in the early stages. The addiction counselor’s role is to assist the client in determining the mode of detoxification that would best meet the client’s needs. If treatment suggests rapid detox or outpatient detox, it is common at this stage to bring in a physician to assist.

Step 4. After the detoxification model is selected, it is important to ensure that the client clearly understands the treatment plan and its action steps. For example, an employee assistance provider who does addiction counseling would assist the client in connecting detoxification to the client’s treatment plan. However, it is vital that the client actively participates in planning his or her treatment with regard to determining space availability, insurance and financial considerations, openings, time, and who needs to be notified (e.g., family and work), so as to instill ownership into this choice of action.

Step 5. The client begins the detoxification process. Upon completion, a clear exit strategy is essential to support the client’s long-term recovery. In addition, the detoxification process might include some multidimensional interventions (e.g., a psychiatrist for dual diagnosis clients who may be prescribed a medication to stabilize mental health issues).

Traditional chemical detoxification
Traditional chemical detoxification is the natural elimination of chemicals in a controlled environment until the chemical is no longer present. The goal is to manage physical withdrawal. As Seymour and Smith (2001) explain, “most withdrawal symptoms are the opposite of the drug’s desired effects and as such represent symptoms that can range from things the patient would rather avoid all the way to potentially fatal effects, such as seizures” (p.67). Approximately 30 percent of opiate-dependent patients who begin detoxification as inpatients do not complete detoxification due to intense cravings and painful withdrawal symptoms during the first three days of detoxification (Addiction Recovery Institute, 2004).

There is no single “right way” to detoxify opioid-addicted patients. Traditional detoxification methods include tapering with methadone, or discontinuing opioids and administering oral clonidine to ameliorate symptoms of withdrawal. Buprenorphine is a newer agent that can be appropriate to use in a detoxification regimen. Even when pharmacological agents are utilized in the management of opioid withdrawal, there is often a significant amount of patient discomfort. Patients who are unwilling to tolerate this discomfort often terminate the detoxification process and return to opioid use (especially illicit use). Thus, relapse to active opioid addiction is a risk factor in any attempt at opioid detoxification.

Rapid detoxification
Rapid detoxification is a relatively new process in North America. It is normally a 4- to 6-hour process, conducted under the guidance and supervision of a board certified anesthesiologist, that began in Europe in the 1980’s and was brought to the United States in 1996 (McCabe, 2000). This program, used primarily for clients addicted to opiates, requires the client be put under a general anesthesia, and administered a medication (two commonly used medications are naltrexone and naloxone), to counteract the physical effects of opiates and allow the body to rapidly withdraw. McCabe (2000) points out that the greatest risks of this process are the use of general anesthesia and the cost of this program, which ranges from $3,550 to $7,000, more than 2 to 3 times the cost of traditional detoxification programs.

An attractive feature of this model is that the client will experience no withdrawal symptoms, no pain, and will awaken from the process with no physical symptoms. With no symptoms comes a new start, as the client will no longer be physically dependent. While withdrawal from opiates is seldom life-threatening, it can be extremely painful and result in the client relapsing to avoid the withdrawal symptoms. Most programs will prepare the client for a recovery period in which he or she may experience mild side effects (e.g., mild nausea and diarrhea) and will recommend the client be put on an opiate antagonist for 6 to12 months. It is important to note: the exact protocols for the detoxification program as well as the exit strategy from the program will vary from program to program and client to client.

For more information on this tool and to find treatment facilities that offer this program, see www.addictionrecoveryguide.org/treatment/patient.html.

Outpatient detoxification
Another form of detoxification that is gaining attention, because it is potentially more cost effective than inpatient programs, is outpatient detoxification. Prater, Miller, and Zylstra (1999) report, “Outpatient detoxification of patients with alcohol or other drug addiction is being increasingly undertaken. This type of management is appropriate for patients in stage I or stage II of withdrawal who have no significant comorbid conditions and have a support client willing to monitor their progress.” Adequate dosages of appropriate substitute medications are important for successful detoxification; by accounting for social and environmental concerns and additional medical conditions, a physician in conjunction with a counselor, providing supportive, nonjudgmental, yet assertive care, can facilitate the best possible chance for a client’s successful recovery (Prater, Miller, and Zylstra, 1999). Outpatient programs average 3 to 14 days (Hayashida, 1998).

It is important to remember that this treatment option must be led by a physician, and the client cannot be in stage III withdrawal. There must be a designated agent who will stay with the client throughout the entire withdrawal process and the client must make daily visits to the physician who is supervising the outpatient detoxification. In order to ensure the success of this treatment program, the client will need to engage in other recovery options such as cognitive-behavioral therapy and self-help groups, counseling, or other outpatient programs. For more information about outpatient detoxification, see Morse (1999). For information about other recovery options, see Howatt (2004) and Howatt and Coombs (2003).

Pharmaceutical medical interventions
It seems that almost everyday CNN is reporting a new and exciting breakthrough in brain research and biochemistry. These breakthroughs have seen drugs such as Antabuse® (disulfiram), which was first sold in 1948 and by 1986 was found to greatly improve abstinence in alcoholics. Similarly, Revia® (naltrexone), originally developed to treat opiate addiction, has been used with great effectiveness to reduce alcohol cravings almost twofold (Kurtzweil, 1996). At this point in time, medications are critical for successful traditional chemical detoxification, managing withdrawal, and harm reduction. Medications assist in reducing pain and discomfort that is associated with the addiction recovery process. Although addiction counselors are not medical doctors who prescribe medications, it is paramount that we stay current and aware of the pharmaceuticals medical interventions currently being used.

Here are a few examples of recent breakthroughs:

1. Ondansetron was developed to prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, anesthesia, and surgery now appears to have potential to offset wtihdrawl symptoms in treating early alcoholism (Food and Drug Administration, 2000).

2. Drug Week introduces the potential hope of a drug called gamma-vinyl GABA (GVG) that is being used in other countries to treat epilepsy. It is showing potential for blocking the effects of cocaine because it raises levels of GABA in neural receptors (Brodie in Ritter, 2003).

3. The Georgia Center for Nicotine Addiction has obtained a U.S. government patent for its one-time medical treatment it claims can eliminate urges and cravings for nicotine. Based on the research where nicotine works similarly to the chemical neurotransmitter acetylcholine, researchers have developed a nticholinergic block method using atropine and scopolamine for obtaining the neurotransmitter block. For more information, see www.nosmokeatlanta.com.

4. The FDA approved two forms of buprenorphine for treating opiate addictions (Elliot, 2002). For current information on issues surrounding buprenorphine, see http://www.jointogether.org/sa/issues/hot_issues/bupe/.

In addition to dealing with primary chemical addictions, medications are effective when managing dual diagnosis (psychiatric disorder in addictions) such as ADHD, general anxiety, posttraumatic stress disorder, depression, psychotic disorders, panic disorders, and phobia disorders. With an increase in dual diagnosis (Minkoff & Cline, 2003), it is important for addiction counselors to refer to texts such as the Clinical Handbook of Psychotropic Drugs by Bezchlibnyk-Butler and Jeffries (2002). It will be important for addiction counselors, as a part of a multidisciplinary team and a primary resource for clients, to keep up-to-date in terms of current medication treatments. For additional resources related to these interventions, see Barber and O’Brien (1999).

Drug testing
Today science has helped to make drug testing a more affordable option to assist clients in maintaining accountability. Drug testing can be an effective recovery tool because it provides a social contract by removing the client’s ability to lie, and it promotes honesty and accountability, which can act as a guide and motivator for compliance.

There are two kinds of drug testing: performance testing (instant drug-testing kits) and toxicological drug testing (requires full-spectrum laboratory testing that is more costly and time consuming). Toxicological testing, the more accurate of the two tests, has a more detailed protocol with set standards for the chain of custody (process for taking sample, time sample is collected, process for shipping to lab, and so forth). Drug testing is commonly a four-step process: collection, screening, confirmation, and review. In drug testing, the samples are called test matrices. The most common test matrices are salvia, hair, blood, and urine. Whether or not addiction counselors use either application of testing directly, it is helpful to be aware of them, as well as to be wary of another important factor: as sophisticated as drug tests are becoming, so are strategies and techniques to defeat them.

Addiction counselors who are involved in drug testing must have clear testing protocols to reduce the potential of error and to increase validity of the tests. It is important with drug testing that a client’s civil liberties (most notably privacy) and laws are taken into account. As drug testing by employers, the criminal justice system, and treatment centers becomes more common, the utility of drug testing will increase. With improved testing protocols and procedures, accuracy and accountability improves. Drug testing, as an accountability tool for managing recovery, is a positive instrument in facilitating recovery. It stands as a veritable recovery contract between the client and the counselor by scientifically measuring compliance.

For additional information on drug testing, consult Baer and Booher (1994), who provide an alternative view, and visit the Drug Alcohol Industry Testing Association (DATIA) Web site, http://www.datia.org/.

The cutting-edge is within reach
Managing recovery is a difficult task even with motivated clients. It is equally difficult to advocate and guide clients toward treatment options that lie on the cutting edge of science, almost beyond the traditional purview of the addiction counselor. Awareness and education is the solution to eliminating anxiety in this process. By investigating the pros and cons of these treatment options, addiction counselors simultaneously assert their place at the table in multidisciplinary treatment teams and position themselves to better align their clients with appropriate treatment options.

William A. Howatt, PhD, EdD, ICADC, a postdoc at the UCLA School of Medicine, serves on the faculty of Nova Scotia Community College and is co-editor (with Robert H. Coombs) of the Wiley Book Series on Treating Addictions. He can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
Addiction Recovery Institute. (2004). Frequently asked questions [Online]. Available: http://www.detox24.com/
questions_answers.html
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed., text revision). Washington, DC: Author.
Baer, J., & Booher, J. (1994). The patch: A new alternative to drug testing in the criminal justice system. Federal Probation, 58(2), 29-33.
Barber, W. S., & O’Brien, C. P. (1999). Pharmacotherapies. In B. S. McCrady & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook. New York: Oxford University Press.
Elliot, V. S. (2002, Nov. 4). Drug expands options for addiction care. American Medical News, 45(41) [Online]. Available: http://www.ama-assn.org/amednews/2002/11/04/hlsc1104.htm
Food and Drug Administration. (2000). Efficacy supplements approved in CY 1999 [Online]. Available: http://www.fda.gov/cder/rdmt/escy99ap.htm
Hayashida, M. (1998). An overview of outpatient and inpatient detoxification. Alcohol Health & Research World, 22(1): 44-46. Available: http://www.niaaa.nih.gov/
publications/arh22-1/44-46.pdf
Howatt, W. A. (1998). Stop that and be healthy: Smoke cessation program. Kentville, NS: A Way With Words.
Howatt, W. A. (2004). The Six C’s: Cognitive-behavioral recovery tools. Counselor, The Magazine for Addiction Professionals, 5(1): 62-66.
Howatt, W. A. & Coombs, R. (2003). Psychosocial recovery tools for addictive disorders. Counselor, The Magazine for Addiction Professionals, 4(4): 58-61.
Kurtweil, P. (1996). Medication can aid recovery from alcoholism. FDA Consumer, 30(4): 22-26.
McCabe, S. (2000). Rapid detox: Understanding new treatment approaches for the addicted patient. Perspectives in Psychiatric Care, 36(4): 113-121.
McCaffrey, B. (2000). Drugs in America. In U.S. Department of State, International Information Programs, Drug Facts and Figures [Online]. Available: http://
usinfo.state.gov/products/pubs/archive/drugfacts/
Mieczkowski, T. (2001). Drug testing: A review of drug tests in clinical setting (pp. 111-123). In R. H. Coombs (Ed.), Addiction Recovery Tools. Thousand Oaks, CA: Sage Publications, Inc.
Mieczkowski, T. (1990). The accuracy of self-reported drug use: An evaluation and analysis of new data. In R. Weisheit (Ed.), Drugs, crime, and the criminal justice system. Cincinnati, OH: Anderson.
Miller, W. R. & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behaviour. New York, NY: Guildford Press.
Minkoff, K., & Cline, C. (2003). Scope of practice guidelines for addiction counselors treating the dually diagnosed. Counselor, The Magazine for Addiction Professionals, 4(5): 24-27.
Morse, G. R. (1999). Detoxification: A guide to the medically assisted withdrawal from addiction. London, UK: Mark Allen Publishing.
Prater, C., Miller, K. E. & Zylstra (1999). Outpatient detoxification of the addicted or alcoholic patient. America Family Physician, 60(4): 1175-83. Available: http://www.aafp.org/afp/990915ap/1175.html
Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy toward a more integrative model of change. Psychotherapy Theory Research and Practice, 19(3): 276-287.
Ritter, M. (2003). Epilepsy drug eyed for cocaine addiction. Associated Press Report. [Online]. Available: http://
www.philly.com/mld/philly/6833383.htm

This article is published in Counselor,The Magazine for Addiction Professionals, June 2004, v.5, n.3, pp. 65-72.

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