Inpatient Detox Centers: A Safe Place to Start Recovery

Alcohol and illicit substance misuse affects millions of Americans. The 2020 National Survey on Drug Use and Health reported that 28.3 million Americans have an alcohol use disorder, 18.4 million have an illicit drug use disorder, and 6.5 million have both. Of those, a little over 800,000 sought treatment at inpatient detox centers.¹

What Are Inpatient Detox Centers?

In a list of principles of effective addiction treatment, detoxification is at the top.²

Substance use disorders—the clinical name for the signs, symptoms, and behaviors associated with substance misuse and addiction—are defined as:³

A cluster of behavioral and physical symptoms, which can include withdrawal, tolerance, and craving.

Withdrawal is a syndrome that occurs when… concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance… Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms with stimulants (amphetamines and cocaine), as well as tobacco and cannabis, are often present but may be less apparent.

Withdrawal management services provided through inpatient detox centers provide a safe, monitored environment to go through the withdrawal process.

Inpatient detox centers are general, addiction, or psychiatric hospitals that provide medical supervision during withdrawal from alcohol and other substances. Some facilities exist within another more extensive hospital system.

What Does Inpatient Detox Entail?

Inpatient detox has a number of different elements to it. Patients who are brought to an inpatient center for treatment can usually expect a structured withdrawal from drugs and alcohol in a safe environment.

Intake and Assessment

Most detox facilities start out with the intake and assessment phase. Patients are admitted to the program, and any important aspects of treatment (such as whom to have as an emergency contact, how treatment will be paid for, etc.) can be worked out here. Then, the patient receives a full examination, including assessment of their substance use history and withdrawal.

Most individuals must be assessed for any co-occurring mental disorders if they haven’t been already. This is because mental illness and addiction often go hand-in-hand.

Induction

The patient then begins their treatment regimen, which is usually a combination of medications to treat and minimize one’s withdrawal symptoms, and behavioral therapies to stabilize the patient and prepare them for addiction treatment. During this phase, medications may be experimented with and doses may be tweaked in order to find the right amount.

Stabilization

The patient will need to be stabilized on their medications as well as in the treatment program. This may take a few days or longer, especially if the individual is experiencing severe symptoms such as drug-induced psychosis or delirium tremens.

In the latter case, treatment may require full sedation for a few days.

Maintenance or Weaning

Once the patient is stabilized, they will either need to be maintained on medication to curb their withdrawal symptoms and cravings or weaned off their medications. This decision is usually made on a patient-by-patient basis (including when each step occurs) based on the doctor’s recommendations for treatment. According to the Journal of Addictive Diseases, “…maintenance medication provides the best opportunity for patients to achieve recovery from opiate addiction.”

Transition into Addiction Treatment

Finally, the patient must make their transition into rehab. Without proper addiction treatment, they will not be able to build a solid recovery.

When in inpatient detox, all of this is done onsite at the facility, and the individual lives among other recovering addicts. Some inpatient detox centers provide more intensive care, especially those in hospitals, while others may feel more like group homes. Usually, treatment like medications, individual therapy sessions, and group therapy sessions occur at the same times every day, and patients are given free time to spend on activities or to reflect on their recoveries.

What Are the Levels of Care at Inpatient Detox Centers?

Detox takes place in a hospital setting with around-the-clock access to a team of licensed and credentialed doctors, nurses, psychologists, counselors, and technicians. These providers can help you overcome your substance use disorder using various tools and methods. It starts with detoxification.

The level of care you need is determined using the Addiction Society of Medicine criteria. Level I-D is the least restrictive and Level IV-D is the most restrictive.

Within these levels, there are five adult detoxification placement levels of care. Level I and Level II address detoxification on an outpatient basis. Levels III.2-D, III.7-D, and IV-D are specifically for inpatient detox centers.⁴

Level III. 2-D Clinically Managed Residential Detoxification

Sometimes referred to as “social detoxification,” Level III.2-D inpatient detox centers provide support throughout the day and night but rely primarily on peer and social support to help you through withdrawal.

A physician evaluates and orders the treatment plan, but it is up to other clinical staff, such as nurses and technicians, to implement and manage the orders.

Level III. 7-D Medically Monitored Inpatient Detoxification

In Level III.7-D centers, “medically monitored” means that a clinical professional observes you during detox, supervises your care, ensures doctor’s orders are followed, and provides medication, if prescribed.

Your care team also includes nurses and other licensed or credentialed staff who encourage you to participate in recovery activities once you are medically stable.

Level IV-D Medically Managed Intensive Inpatient Detoxification

Detox symptoms require more supervision in IV-D inpatient detox centers, so doctors are accessible 24 hours a day. Nurses assess and monitor signs every hour and administer medication ordered by the physician.

Who Benefits from Inpatient Detox Centers?

Medically monitored and managed inpatient detox centers are necessary for people at risk for severe withdrawal symptoms.

Specific Substances

All substances pose a risk of withdrawal complications, but alcohol and benzodiazepine withdrawal, specifically, are recognized as being potentially life-threatening. Inpatient detox is recommended if you are detoxing from alcohol or benzodiazepines and have moderate to severe symptoms. Opioid withdrawal is rarely fatal but it can cause severe symptoms, as well.

Medication-assisted treatment (MAT) treats alcohol and opioid use disorders, but they are the only substances the Federal Drug Administration has approved medication. Medications ease withdrawal symptoms and cravings. The goal behind medication management is to help you engage in treatment with a clear mind. Over time, as progression in recovery occurs, your doctor will taper the MAT until you are substance-free.⁴

Additional Health Considerations

If you have a physical health condition, psychological disorder, or both, detoxing in an acute hospital setting may also be safer, less painful, and more effective than detoxing in an outpatient setting.⁵

Severe Substance Use Disorders

One study shows inpatient treatment is more effective for those with severe alcohol use disorder. Significant findings are that those in inpatient detox centers had more alcohol-free days, and on the days they did drink, they consumed alcoholic drinks than before.⁹

Do Not Qualify for Intensive Outpatient Programs

Inpatient detox centers benefit people who qualify for a higher level of care than intensive outpatient programs (IOP). Criteria for inpatient detox centers and IOPs differ in that the person in outpatient treatment:⁶

• Does not require medical detoxification
• Does not require 24-hour medical supervision
• Is not at risk for severe withdrawal symptoms that could lead to adverse health consequences

Who Needs Inpatient Detox But Isn’t Getting It?

The number of people with substance use disorders who receive any addiction treatment in any given year is extremely low.

The United States Surgeon General has identified specific populations who need treatment but are not receiving it in disproportionate numbers compared to the general population based on responses from the National Survey on Drug Use and Health:⁵

• Over 7 million women
• Over 1 million adolescents between 12 and 17
• Over 3 million Hispanics
• Approximately 3 million African Americans
• Over half of respondents with co-occurring disorders

The Surgeon General and the Department of Health and Human Services have developed plans for outreach to bridge the treatment gap and reduce disparities at all levels of treatment. This includes intervention for all forms of treatment, including detox.⁵

The Criminal Justice System

Researchers note that individuals involved with the criminal justice system need access to inpatient detox centers. Detoxing in custody—whether in the local police precinct or in federal prison—can be dangerous because there is no specifically trained medical personnel present to respond to an immediate emergency.

Research indicates that court-mandated rehab can be just as effective as voluntary rehab. However, patients must be medically stable before they can enter rehab.

Facilitated access to inpatient detox centers would allow individuals in custody, incarcerated, and on probation to jumpstart the process of stepping down through the continuum of care.

Addiction treatment programs for individuals involved with the criminal justice system have been shown to help with overcoming specific problems associated with criminality, such as:⁷

• Accepting responsibility
• Decision-making skills
• Building drug-free supports
• Receiving vocational assistance
• Learning to feel rewarded without criminal activity
• Receiving treatment for co-occurring disorders
• Receiving medication-assistance treatment when needed

Reports indicate that two-thirds of criminals detained in jails and half of state prison inmates have substance use disorders. However, only about 10% receive treatment specifically for their substance use disorder.⁷

Active-Duty Military and Veterans

Substance use disorders are prevalent in the military due to a number of demographic-specific risk factors.

Neither active-duty servicepersons nor veterans receive consistent addiction treatment at the level that research indicates is needed. Domestically, the military could benefit from structured, medically supervised inpatient detox centers, either run by the VA or civilian organizations. Then they can transfer patients to additional treatment to learn recovery skills.⁷

How Long Is the Stay at Inpatient Detox Centers?

Detox is often the first step in overcoming substance use disorders. It is not considered an effective single treatment to achieve long-term, sustainable recovery.

How long a person stays at an inpatient detox center varies and may be influenced by the severity of their substance use disorder and withdrawal symptoms. Each substance creates its own set of withdrawal symptoms.⁸ If you have a polysubstance use disorder, withdrawal symptoms can overlap and make management more challenging.

Comparing substances, such as alcohol and opioids, can illustrate the need for different lengths of stay. Alcohol withdrawal symptoms can appear as early as 4-6 hours after a person’s last drink. Over the next 2-7 days, withdrawal symptoms can appear mild, moderate, or severe. Mild withdrawal symptoms include nausea, vomiting, chills, and fever. Severe symptoms include seizures and delirium tremens.⁸

Opioid withdrawal symptoms may not appear for 12 hours and peak at 72 hours after last use. Depending on the opioid, withdrawal symptoms can linger for two weeks or longer. Although the withdrawal symptoms are milder, they can last a lot longer.⁵

Once your vitals are stable and your symptoms have subsided, your treatment team will decide when to discharge you from inpatient detox.

What Protocols Are Used at Inpatient Detox Centers?

When entering inpatient detox centers, you can expect different protocols than at an outpatient program. The setting is one of the most significant differences. Inpatient detox centers are hospital settings, whereas outpatient programs are free-standing facilities in the community.⁵

Most inpatient detox centers stabilize a person experiencing severe withdrawal symptoms using medication and medical support. Out of those who received treatment for alcohol use disorder, in 2020, 362,000 did so with medication-assisted treatment (MAT) to reduce alcohol misuse. Of those with an illicit drug use disorder, 11.2% received MAT for opioid use disorders and 30.5% for all other illicit substances.¹

Medications used to treat withdrawals from alcohol include:¹⁰

• Acamprosate
• Naltrexone
• Benzodiazepines
• Disulfiram
• Anticonvulsants

Medications approved for withdrawal treatment involving opioids include:¹¹

• Buprenorphine
• Methadone
• Clonidine
• Tramadol
• Naltrexone

While people in inpatient detox centers have access to counselors and peer support, learning new relapse prevention and recovery skills begins after detox, typically in inpatient rehab or intensive outpatient programs (IOPs). These next steps help:⁵

• Address social and emotional problems
• Build social supports
• Learn new coping skills

For many individuals who have used substances for a long time or in heavy amounts, the recommended protocol is inpatient detox, followed by a step down to inpatient rehab, then intensive outpatient, and finally individual counseling and other services.

Find the right inpatient detox center by calling 800-996-6135(Who Answers?) .

Resources

1. Substance Abuse and Mental Health Services Administration. (2021). Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.
2. Center for Substance Abuse Treatment. (2015). Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 45. Rockville, MD: Substance Abuse and Mental Health Services Administration.
3. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association Publishing.
4. American Society of Addiction Medicine. (2004). ASAM Pyramid: ASAM Levels of Care for Adult Detoxification.
5. U.S. Department of Health and Human Services. (2016). Office of the Surgeon General (US). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [Internet]. Washington (D.C.): Substance Abuse and Mental Health Services Administration (US).
6. McCarty, D., Braude, L., Lyman, D. R., Dougherty, R. H., Daniels, A. S., Ghose, S. S., & Delphin-Rittmon, M. E. (2014). Substance Abuse Intensive Outpatient Programs: Assessing the Evidence. Psychiatric Services, 65(6), 718-726.
7. Mirijello, A., D’Angelo, C., Ferrulli, A., Vassallo, G., Antonelli, M., Caputo, F., Leggio, L., Gasbarrini, A., & Addolorato, G. (2015). Identification and Management of Alcohol Withdrawal Syndrome. Drugs, 75(4), 353-365.
8. National Institute on Drug Abuse. (2020). Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide.
9. Kosten, T. R., & Baxter, L. E. (2019). Review Article: Effective Management of Opioid Withdrawal Symptoms: A Gateway to Opioid Dependence Treatment. The American Journal of Addictions, 28(2), 55–62.
10. Hammond, C. J., Niciu, M. J., Drew, S., & Arias, A. J. (2015). Anticonvulsants for the Treatment of Alcohol Withdrawal Syndrome and Alcohol Use Disorders. CNS Drugs, 29(4), 293-311.
11. U.S. National Library of Medicine. (2022). Opiate and Opiate Withdrawal. MedlinePlus.