Recovery from addiction rarely follows a straight line, so knowing whether or not progress is being made is not always clear. Unfortunately, valid tools for measuring process in recovery are in short supply. Even a shorter-term stage of recovery – detoxification – can be difficult to track, despite the existence of multiple scales, such as the “CIWA” (Clinical Institute Withdrawal Assessment for Alcohol) and “COWS” (Clinical Opiate Withdrawal Scale). As a result, deciding how much medication to give a patient to assure safety and provide comfort can be difficult.
There is no evidence that a painful detoxification helps with measuring progress of recovery or has a positive motivating effect on someone struggling with a substance use disorder. The opposite is often the case – a person will continue to drink or drug and will avoid treatment because of fear of withdrawal discomfort. During outpatient detoxification at Kolmac, our goal is to eliminate acute withdrawal symptoms within one to four hours without creating side effects by over-medicating.
The best way that we have found to accomplish this is by allowing our medication decisions to be guided by this single global withdrawal discomfort question:
- “On a scale of zero to 10, where zero is the complete absence of any withdrawal symptoms and 10 is the worst symptoms you have ever had, what number would you put on your withdrawal discomfort right now?”
To the number reported by the patient, we add information about past withdrawal history as well as observations about current signs and symptoms, such as elevated vital signs, sweating, and tremor. This helps us with measuring progress with recovery. Once we have established this baseline we begin the hourly administration of medication and watch for changes – the most important of which is the subjective discomfort number. The degree and speed with which that number declines are the main drivers of decisions about how much and how often to provide medication.
Because early withdrawal is an evolving process in which symptoms intensify over time, a report by the patient that the discomfort number is not getting higher can be an indication that progress is already being made. We can realistically reassure the patient that, while we have not reached our goal, we are on the right track, which can reduce the patient’s anxiety about serious withdrawal consequences.
More attention is being paid these days to the treatment of post-acute withdrawal symptoms – a collection of nagging discomforts including sleep, mood, anxiety, and a general sense of wellbeing – that can persist for months. Medications such as gabapentin can help reduce these, but we are still in search of good ways of measuring progress with recovery.
Contact us to learn more about measuring progress with recovery.