Ask an Expert: What Options Are There For Detox?

By Larissa Mooney 01/08/15
Today's question is on what types of detox work best for whom.
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What exactly are the options for opiate/heroin detox? I have heard of: methadone, Suboxone, Subutex, Naltrexone - orally and by injection – Ibogaine (in mexico only?). Which types of populations work the best for each option? i.e., is naltrexone an option for the poor/poverty populations on state funded “insurance?” What do the rich people do? What is typically given to people with no money?

Larissa Mooney: Opioid withdrawal causes significant physical discomfort and increased relapse risk. Medications may be used to alleviate symptoms, including muscle aches, abdominal cramping, nausea, vomiting, diarrhea, anxiety, restlessness, sweating, yawning, and elevated blood pressure and pulse. There are several options for opioid “detoxification” involving either long-acting opioids, including methadone or buprenorphine, or non-opioid medications, such as clonidine in combination with other supportive medications. Clonidine is an antihypertensive that reduces the severity of acute withdrawal symptoms.

Detox typically occurs in medically supervised settings and lasts at least several days; the goal is to minimize withdrawal symptoms and facilitate transition to abstinence-based treatment. 

It is true that the choice of treatment is often influenced by insurance coverage and other financial considerations. Facilities may have a preferred approach shaped by clinician experience, local policies and state laws. Non-opioid detox approaches typically include the use of additional supportive medications that are often given in combination with clonidine. These include anti-inflammatories for muscle aches, antinausea medications, antidiarrheals, and sleep medications.

Methadone, a long-acting opioid prescribed for both chronic pain and opioid maintenance therapy, may be used for outpatient opioid detoxification within federally licensed treatment programs.  Buprenorphine, a long-acting partial opioid, may also be prescribed within outpatient or inpatient settings and by individual practitioners. The duration of the detox may be relatively short (i.e. within one week) or longer, depending on patient and clinician preference.

Depending on financial issues and clinical factors, both methadone and buprenorphine may also be prescribed for longer term opioid maintenance treatment. Relapse rates to illicit opioid use are very high after “taper,” the term used for gradual reduction of medications. Recently detoxified patients may also be transitioned to the opioid blocker, naltrexone which is available as a daily pill or monthly injection.  Ideally, comprehensive treatment planning after detox incorporates psychosocial therapy and support to optimize long-term success.

Ibogaine is a psychoactive plant-based compound that has been used in the treatment of drug addiction outside of conventional medical settings. It has been reported to reduce opioid withdrawal and cravings, and some individuals have reported longer term abstinence from opioids following treatment. Largely due to medical safety concerns (including cardiac risk and reports of sudden death) and to a lack of research data supporting its use, ibogaine treatment and possession is illegal in the U.S. It is available for treatment and use in Mexico, Canada and some European countries. 

A wide variety of factors determine which treatments are available for wealthier vs. less wealthy individuals. In general, methadone and non-opioid-based detox options are less expensive and more widely covered by insurance plans (including Medicaid-based coverage). Buprenorphine is more costly, and availability may be limited by insurance formularies and out-of-pocket expenses.

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Larissa Mooney, MD, is the Director of the Addiction Medicine Clinic at University of California, Los Angeles, and is a board certified addiction psychiatrist with expertise in the treatment of substance use disorders and psychiatric co-occurring disorders. She is also Assistant Clinical Professor of Psychiatry at UCLA.www.LarissaMooneyMD.com   Full Bio.

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