Detoxification can be defined as the means by which the drug-dependent person may
withdraw from the effects of that drug in a supervised way in order that withdrawal
symptoms and the risks relating to withdrawal are minimised.
The recommendations of Richmond and Webster (1988) present a very useful approach to
assisting patients to quit. There are a number of important principles:
people have different levels of readiness for change
people should be offered the opportunity to take each step which progresses to quitting
and staying stopped
people need to weigh up the costs and benefits of smoking and quitting
people should be assisted to develop a specific action plan including written advice and
information
people should be offered support to quit: at home, at work and by health workers
people are assisted by systematic follow up
people may need specific help to stay stopped, eg nicotine gum, lifestyle counselling.
Various approaches
The 'happy user'
These people should be informed about the risks to which they expose themselves and
others. Provide written material to reinforce the information you have told them.
Those thinking about quitting
These people can be assisted by encouraging them to:
review their tobacco use.
estimating their nicotine dependence
weigh up costs and benefits of smoking and quitting
provide them with verbal and written information about stopping.
Those who have
decided to quit
These people can be helped to do so by:
helping them assess their specific risk factors
habit patterns
nicotine dependence
high risk situations
their confidence in stopping
helping them to develop a specific plan
set a quit day
anticipate craving and withdrawal
identify situations when there may be a temptation to smoke (eg with coffee, alcohol,
when stressed)
devise tactics to assist in coping with withdrawal symptoms:
Delay: a tactic to reduce
feelings of panic or anxiety, by continually delaying having a cigarette. After a few days
craving will lessen and a sense of achievement and confidence will emerge.
Distract: make a conscious effort to do something when a craving emerges. This may
include counting, exercise, working, eating, drinking etc.
Avoid: for the first two weeks try to avoid those high risk situations, triggers or
cues which may produce craving for a cigarette. These may include coffee, alcohol, the
pub/club, smoking friends etc. Over time these situations will be able to be faced with
confidence.
Escape: from situations that produce cravings when the tactics above fail. Leave the
room, go outside or make a phone call. Such action will lower the urge to smoke and
previous activities can be continued.
providing them with verbal and written information on how to stop smoking
planning with your patient ways to cope with a relapse. Explain that relapse is common
and encourage them to try again or refer them to a specialist stop smoking clinic
some patients may prefer to use a nicotine gum. Carefully explain the most effective way
to gain results through this form of management. In particular, stress the need to chew
the gum slowly and persist with the treatment for three months. Many people who have not
found this form of treatment successful have not used the gum as instructed.
Staying stopped
These people can be assisted by:
providing support and encouragement
helping them identify the most difficult situations
Detoxification from psychostimulants is generally effective using non-pharmacological
management techniques. While abstinence is the preferred treatment goal, there is no
evidence to suggest that tapered withdrawal is any less effective in the cessation of
psychostimulant use. All patients undertaking detoxification should be encouraged to
abstain from the use of other mind-altering drugs, such as alcohol or marijuana, which may
act as triggers or conditioned cues for the use of psychostimulant drugs or reduce the
ability of the individual to cope with cravings experienced during withdrawal.
While most patients can undertake detoxification in an outpatient program, inpatient
treatment may be more appropriate in the following circumstances:
evidence of polydrug dependence
where severe withdrawal is anticipated
medical complications requiring close observation or treatment
Where inpatient treatment is
necessary, programs should be tailored to the specific needs of the patient. While the
goals of individuals will differ, all patients should remain in inpatient care until
withdrawal symptoms subside.
Non-pharmacological treatments
There are a number of options available, all of which will not be appropriate for all
patients.
Motivational interviewing
Behavioural approaches
relaxation techniques
undertake activities to delay cravings
develop cognitive techniques which encourage the individual, and discourage the use of
drugs
encourage relapse prevention techniques (eg identifying, avoiding and dealing with high
risk situations; learning to say no)
contingency contracting techniques have been effective in reducing ambivalence toward
ceasing cocaine use. The use of positive contingencies to reward non-use has shown
increased participation and improved outcomes.
Supportive therapy – the aim of this treatment is to educate the user about the
realities of their drug use and its consequences. A number of lifestyle changes may be
recommended:
dissociation from other drug users
the disposal of drug-using equipment
encourage identification, avoidance and coping techniques to deal with high risk
situations
Psychotherapy/counselling – found to be effective among a minority of users. This
technique encourages individuals to identify the role of the drug in their lives in order
to give them an increased sense of control
Family therapy – the family is often included in treatment programs because they
have the potential to perpetuate changes in patterns of behaviour which may model an
individual's drug use.
Self-help groups – groups such as AA, NA and CA are effective support sources for
some individuals
Pharmacological interventions in psychostimulant use
Pharmacologic interventions are used to achieve and sustain abstinence through the
reduction of withdrawal symptoms. While most cases do not require drug treatment, where
necessary, pharmacological interventions should be tailored to the needs of the individual
and used in addition to a comprehensive treatment program.
Note: The treatments outlined below have been extrapolated from cocaine management data
and therefore it is not known how effective they will be in the management of amphetamine
detoxification.
Desipramine is the drug of choice. When used in conjunction with bromocriptine or
amantadine (both dopamine agonists), reduced craving and dysphoria are reported during
cocaine withdrawal.
Desipramine – starting at 25-30 mg nocte and increasing to 50-150 mg per week as
clinically tolerated until reaching a maximum dose of 150-300 mg nocte.
Bromocriptine – starting at 0.625 mg three times daily, gradually increasing to
7.5-12.5 mg divided three times a day, as clinically tolerated, for 14 days.
Amantadine – has been found to be as effective as bromocriptine in reducing cocaine
craving
Pharmacological treatment can continue if cravings recur.
Methylphenidate, which has amphetamine-like properties, has been shown to be an
effective treatment in individuals with pre-existing adult attention deficit. Likewise,
lithium has been an effective treatment among individuals with bipolar or cyclothymic
disorders.