Heroin detoxification programs

The term detoxification implies a clearing of toxins. However, for individuals with physiological substance dependence/addiction, heroin detoxification is usually related to withdrawal syndrome, that is, the predictable constellation of signs and symptoms following abrupt discontinuation of, or rapid decrease in, intake of a substance that has been used consistently for a period of time.

In fact, the withdrawal syndrome is the main obstacle to recovery of an addiction. That is because persons who are severely dependent on heroin, abrupt, untreated cessation of consumption may result in severe discomfort. But risks to the patient and society are not limited to the severity of the patient's physical disturbance, particularly when the detoxification program is conducted in an outpatient setting. Outpatients experiencing withdrawal symptoms give up treatment more often, may self-medicate, and the interaction between prescribed medication and self-administered drugs may result in an overdose or brain damage.

Signs and symptoms of acute opiate withdrawal can emerge within hours of cessation of short-acting drugs (such as heroin), peak within 36 to 72 hours, and subside over a period of seven to 10 days. Signs and symptoms of withdrawal from long-acting opiates (such as methadone) begin 24 to 48 hours after the patient's last dose, peak on or after the third day, and gradually subside over several weeks.

About 8-12 hours after their last heroin dose, addicts' eyes tear, they yawn and feel anxious and irritable. Excessive sweating, fever, stomach and muscle cramps, diarrhea and chills can follow several hours later. The withdrawal syndrome involves gastrointestinal and musculoskeletal symptoms, anxiety, dysphoria, craving and manifestations of sympathetic hyperactivity. The phrase 'cold turkey' probably comes from the appearance of goose bumps all over the body, which resembles a plucked turkey. Muscle spasms in the legs produce kicking movements, and this may be the derivation of the expression 'kick the habit.' These withdrawal symptoms can continue for 1 to 3 days after the last dose and can last 7 to 10 days. In some cases, full recovery can take even longer.

For these reasons, heroin detoxification programs without the appropriate medical management and level of care constitute a great risk for health of patients. On the other hand, the harshness of the withdrawal syndrome leads to a very high risk of relapse during the early withdrawal period, in part because the drug craving is easily triggered by encounters with or thinking of drug-associated stimuli.

To avoid brain damage risk: Ultra Rapid Opiates Detoxification (UROD) without withdrawal

As mentioned before, withdrawal symptoms are a fundamental obstacle for heroin detoxification treatment. This is because withdrawal from consumption of heroin is not sufficient to eliminate the serious alterations that heroin produces in brain cells. Moreover, current medications used in detox treatment programs do not restore damaged areas, but mask symptoms.

Once in the brain, drugs affect chemicals called neurotransmitters. These are the chemicals that control the flow of information within the brain between the neurons or brain cells, forming a synapse. Neurotransmitters also alter people's moods and feelings.

Opiates stimulate a "pleasure system" in the brain. This system involves neurons in the midbrain that use the neurotransmitter called "dopamine." These midbrain dopamine neurons project to another structure called the nucleus accumbens which then projects to the cerebral cortex. This system is responsible for the pleasurable effects of heroin and for the addictive power of the drug. Other neurotransmitter systems, such as those related to endorphins, are also likely to be involved with withdrawal from and tolerance to heroin.

Once in the brain, the heroin is converted to morphine by enzymes; the morphine binds to opiate receptors in certain areas within the reward pathway of the brain, as part of the cerebral cortex, the VTA, nucleus accumbens and thalamus. Morphine also binds to areas involved in the pain pathway (including the thalamus, brainstem and spinal cord). Binding of morphine to areas in the pain pathway leads to analgesia. Three types of neurons participate in opiate action; one that releases dopamine, a neighboring terminal containing a different neurotransmitter (probably GABA for those who would like to know), and the post-synaptic cell containing dopamine receptors. Opiates bind to opiate receptors on the neighboring terminal and this sends a signal to the dopamine terminal to release more dopamine.

Therefore, to avoid the withdrawal syndrome, it is necessary to restore brain functions that have been damaged by heroin addiction. But this is not possible just with detox. Neurons must be recovered, so they can maximize the use of available oxygen and thus neural membrane metabolism is normalized. Only this pharmacological intervention, to recuperate the normal neural functioning of the brain structures harmed by heroin, allows a detoxification without withdrawal symptoms and without craving. Moreover, it allows the recovery of higher cognitive and affective processes as attention, reading abilities, conciousness or serenity.

Because there is a risk of serious adverse consequences for most patients who undergo withdrawal, it is necessary an advanced pharmacological treatment in a medically-monitored inpatient detoxification. This is an organized service delivered by medical and nursing professionals, who provide for 24-hour medically supervised evaluation and recovery management in a permanent facility with inpatient beds. Services are delivered under a defined set of physician-approved policies and physician-monitored procedures or clinical protocols.

Advantages of inpatient detoxification are that (1) the patient is in a protected setting where access to substances of abuse (drugs) is restricted, (2) the management and monitoring of neural recovery eliminates craving, and allows a detoxification without withdrawal, and (3) heroin detoxifciation can be accomplished more rapidly than it can in an outpatient setting. Besides, detoxification with hospitalization prepares the patient for ongoing treatment of his or her dependence on drugs. During detoxification, patients may form therapeutic relationships with treatment staff or other patients, and may become aware of alternatives to a drug-using lifestyle. Detoxification is an opportunity to offer patients information and to motivate them for longer-term treatment.

According to these needs, heroin detox involves several procedures

First, treatment of patients who are under the influence of, or experiencing withdrawal from, substance-related disorders requires an understanding of the natural history and variants of such syndromes; a complete assessment of the patient's individual medical, psychiatric, and social issues. Detailed clinical exploration is necessary, as well as psycho-diagnostic and psychopathological examinations, to establish the characteristics of the addiction and its intensity, the existence of associated psychological illnesses, and the repercussions on the patient family, work, and friendships.  This medical assessment is important in order to determine the need for medication and medical management, and the patient assessment should identify coexisting medical and psychiatric conditions and heroin-related medical complications. Besides, this information is necessary to design the psychotherapeutic strategy during hospitalization which is later continued on an out-patient basis after the patient's release.

Afterwards, oral and intravenous pharmacological interventions are performed to recuperate the normal neural functioning of the brain structures harmed by heroin (for example the locus coeruleus, ventral tegmental area, or adrenergic systems).  The goal of pharmacologic management is to provide the amount of medication necessary to ensure safe and comfortable detoxification, as these interventions allow a detox without withdrawal symptoms and without craving; by increasing the ability of the treated neurons to take advantage of available oxygen, neural membrane functions are normalized in a short period of time.

General management also includes maintaining adequate fluid balance, correction of electrolyte deficiencies, and attendance to the patient's nutritional needs. Brain nutrition involves enriching the patient's diet with salts, oligo-elements, and amino acids essential for neural recuperation and correcting nutritional deficiencies which frequently accompany this illness.

At the same time, a personalized psychotherapy action plan is design, based on the psycho-diagnostic examinations, to restore the harmony between personal and familial psychological functioning, clarify erroneous concepts regarding the illness, and promote attitude and lifestyle changes, all of which incorporate the patient as an active participant in his/her own rehabilitation process.  This psychotherapy, as well as pharmacological control, are process of ambulatory follow-up phase, after the patient leaves hospital.

Under these conditions, the heroin detoxification has four immediate goals: (1) to provide a safe withdrawal from heroin dependence and enable the patient to become free of non-prescribed medications; (2) to provide a withdrawal that is humane and that protects the patient's dignity; (3) to provide a recovery of higher cognitive and affective processes, and (4) to prepare the patient for ongoing treatment of his or her new life.

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