“When you’re going through hell, keep going.”
—Winston Churchill
That saying really hits home in a conversation surrounding AUD and SUD withdrawal. Sure, it wasn’t coined with that in mind, but enduring the detoxification process is the first step in recovery, and while it might be the easiest to beat, it sure doesn’t feel like it if you don’t have medical assistance.
Going “cold turkey” simply isn’t possible when you’re detoxing from certain drugs. Benzodiazepines, aka Xanax, Klonopin, and Valium, have such a hold on the nervous system that suddenly stopping them cold turkey cold mean you end up seizing and falling into a coma. AUD detox involves the same seizure risk.
Medically assisted detox protocols at inpatient recovery programs use medications to help the patient overcome the worst withdrawal symptoms associated with AUD and SUD.
There’s quite a few drugs used in these programs, but in this post we’re going to talk about “Clonidine.”
This drug has an interesting profile, and it’s officially classified as a “alpha-2 adrenergic agonist,” developed initially as a blood pressure medication, with other off label uses in ADHD management and—for the purposes of this post—medical withdrawal from SUD and AUD.
When an addict abstains from using drugs or drinking, they enter withdrawal from those substances. Withdrawal can last for hours or days, depending on the substance of choice and the person’s tolerance to their substance of choice.
But what is withdrawal anyway? Why does it happen? When a users enters withdrawal they experience an ever-increasing activation of the Sympathetic Nervous System (SNS). The SNS, along with the Parasympathetic Nervous System (PNS) are the two branches of our Central Nervous System (CNS).
When withdrawal sets in the stress from the body’s dependence on the drug activates the SNS via the release of the neurotransmitter, “norepinephrine.” When this happens, the user starts to experience the physical manifestation of symptoms like sweating, anxiety, muscle ache, and severe insomnia.
Clonidine blocks the reuptake of norepinephrine by the SNS, reducing the severity of the withdrawal symptoms. It won’t remove them entirely, but it sure does make the process a lot easier on the patient.
Opioids are the leading killer of Americans aged 18 to 45. That’s a shocking statistic, with Fentanyl being responsible for the bulk of those deaths. Synthetic opioids are incredibly potent and addictive substances and the withdrawal process involves nasty physical symptoms like anxiety, muscle aches, agitation, sweating, insomnia, and abdominal cramping caused by overexcitement of the SNS.
It’s important for us to note at this stage that medically managed detox protocols involving Clonidine are not the holy grail for addiction recovery. It’s simply a tool to help the patient through the initial process of withdrawing from alcohol or substances. The patient will still experience mild withdrawal and they’ll have to learn to develop coping strategies to deal with the psychological effects of withdrawal when they enter recovery and their outpatient program.
That said, many addicts don’t enter recovery because they’re afraid of getting sick when withdrawal kicks in. Clonidine makes the thought of recovery easier to manage, and there’s a better chance of an addict choosing recovery if they know they won’t experience the excruciating effects of severe withdrawal from opioids.
Benzodiazepines like Xanax and Valum are anti-anxiety drugs prescribed by doctors to treat anxiety disorders. Like alcohol and opioids, “benzo’s” are a nervous system depressant, activating parts of the SNS and PNS to lower blood pressure and heart rate while limiting the effect of the “fight-or-flight” response by the SNS when exposed to stress.
As with opioids and alcohol, when an addict enters withdrawal from benzo’s, they experience withdrawal symptoms associated with the overstimulation of the SNS and the perpetual activation of the fight-or-flight response. Clonidine blocks adrenaline reuptake in the CNS, limiting this response in the body, thereby reducing the severity of symptoms felt by the patient during the detox process.
Doctors will usually administer Clonidine alongside other medications like long-acting benzos or anticonvulsant drugs in a detox protocol. Since benzos are essentially an antianxiety drug, the patient should undergo full psychological and medical evaluation for any co-occurring mental health disorders alongside their addiction before planning the treatment.
Alcohol Use Disorder (AUD) affects millions of Americans. While many can enjoy a drink with friends, some people end up developing life-altering addictions to alcohol. Like all other substance abuse problems, AUD is a “chronic” disease. That means that you’re never really free of it, and you’ll need to manage your condition for the rest of your days.
Withdrawal from AUD is severe. We might think that it wouldn’t be so bad considering alcohol is readily available almost everywhere you turn. From bars lining the streets to convenience stores selling booze, it’s everywhere, making it easy to access and socially acceptable.
But AUD withdrawal can be life-threatening and has a similar effect on the nervous system and brain as benzo’s do. That means the patient is at risk of seizing and possibly landing in a comp if the withdrawal is too severe for the CNS to handle.
Clonidine once again comes to the rescue, providing a soothing effect to the SNS response, and alleviation of the fight-or-flight state in the patient. As with benzo withdrawal, doctors may include Clonidine treatment alongside other drugs like Lorazepam in MAT protocols.
While Clonidine might sound like a life-saving drug—and for many addicts, it is—like all prescription medications, it comes with a list of side effects. These side effects are mild and nothing to be concerned with. That’s said, the patient should undergo strict medical supervision during the medically assisted detox to ensure they receive the proper treatment and that it has the intended effect.
Here are some of the common side effects associated with Clonidine administration in medically assisted withdrawal protocols.
The side effects are easily managed by a medical doctor in a professional inpatient detox setting. Clonidine isn’t an FDA-approved withdrawal medication, it’s used “off-label” for treating AUD and SUD withdrawal. In cases where it’s used in medically managed detox protocols, a doctor must be present to manage the process and tightly control the administration of the drug to the patient.
The patient must be carefully assessed and screened before the doctor adds Clonidine to their detox protocol. Clonidine interacts with other drugs and may induce complications in patients if the doctor doesn’t correctly assess and diagnose the patient before treatment.
Clonidine mainly plays a supporting role in SUD and AUD detox protocols. It usually takes a back seat to other medications and doctors will only add it to the protocol if they’re certain it adds value to the treatment. The doctor will always look to treat the patient with as few drugs as possible and the minimum dosages required to deliver the intended effect.
In the case of opioid and opiate withdrawal the doctor may run Clonidine alongside other full or partial opioid agonist medications like buprenorphine and methadone to round out the treatment. The buprenorphine and methadone binding to opioid receptors while the clonidine binds to different receptors in the central nervous system. In Rare cases, doctors may administer Clonidine alone if agonist treatment isn’t available or not the preferred choice.
With AUD withdrawal, doctors utilize Lorazepam, chlordiazepoxide, and—surprisingly—benzodiazepines as the base medications for the detox protocol. These medications reduce the risk of the patient experiencing delirium tremens and seizures. The physician may also use Clonidine in AUD withdrawal to manage symptoms of anxiety and high blood pressure.
While it’s not the front-line medication used in AUD detox protocols, it does make for an effective addition to the treatment where necessary. As with all medications involved in MAT procedures, the patient should undergo a through medical evaluation before the doctor prepares the detox protocol.
Let’s take a quick look at how Clonidine compares against the use of other conventional medications in medical detox protocols.
Like we mentioned earlier, it’s surprising to learn that doctors rely on benzodiazepines when treating AUD. These benzo’s have long esters, meaning they have longer half lives than other drugs in this class, like the infamous Xanax (the brand name for Alprazolam). These benzos are considered the benchmark standard for medical AUD detox protocols.
Benzo’s act on the sympathetic nervous system, calming the fight-or-flight response. They reduce anxiety and the potential for seizure risk associated with AUD withdrawal. Doctors typically prescribe lorazepam and diazepam for the detox because they act on the neurotransmitter GABA and its reuptake in the brain and nervous system. They offer widespread relief for the user during withdrawal, helping them deal with the worst of the symptoms.
Clonidine can play a supporting role in the detox protocol, and it’s occasionally used alone when benzos aren’t available or they present an over-sedation risk in polypharmacy protocols. Clonidine lowers heart rate and manages the SNS nervous system response to lower anxiety and stabilize the patient.
Once again, it’s critical for the medical doctor to properly evaluate the patient before planning their medically assisted detox protocol.
Methadone has been the gold standard for opioid and opiate medical detox for decades. While methadone is the primary drug doctors turn to when detoxing patients, it might not always be the best medication for the task. Methadone also comes with dependency risk, and the addict might end up trading one addiction for another.
Doctors may therefore decide to go with Clonidine as a supporting treatment to reduce the SNS excitement caused in the withdrawal process. The methadone acts as an opioid agonist on the opioid receptors while the Clonidine controls the nervous system response.
As mentioned, medical detox protocols, no matter how carefully panned or how they’re structured, will not totally remove all withdrawal symptoms. These medication assisted therapies are designed to help the patient make it through the worst symptoms of withdrawal virtually unscathed, but there will be lingering psychological addiction.
That’s why MAT protocols are simply one cornerstone of a holistic recovery program. The patient will need counseling and support, as well as comprehensive aftercare planning to learn how to deal with their addiction and move on with their life.
There is plenty of ongoing research into the use of Clonidine in medically managed withdrawal protocols. The off-label use of the medication in these treatments garnered attention from the medical community and we can expect some interesting research projects and clinical advancements in the application of this drug in withdrawal protocols in the coming future.
Studies include research into effective dosing protocols to minimize side effect risks while increasing the efficacy of the drug in users. There are already studies and research projects looking into developing longer esters of this drug for sustained release and minimal side effects due to the need for fewer doses in the protocol.
Research into how biological and genetic markers play a role in a patient’s response to the drug will also come into play soon. These clinical breakthroughs will give doctors more insight into the patient’s neurobiological mechanisms and how clonidine modulates their neural pathways to improve treatment outcomes.
Clonidine is a blood pressure medication used in off-label applications for the medical detox of AUD and SUD patients.
It acts on the central nervous systems, specifically the sympathetic nervous system, limiting the activation of the fight-or-flight response during withdrawal.
Clonidine is often used as a supporting drug alongside other medications in medical detox protocols.
There are mild side effects associated with its use in MAT protocols, but the benefit often outweighs the risk for the patient.
While Clonidine might not replace drugs like benzodiazepines and opioid receptor agonists like methadone, it has a place in medically managed detox protocols.
Britney Elyse has over 15 years experience in mental health and addiction treatment. Britney completed her undergraduate work at San Francisco State University and her M.A. in Clinical Psychology at Antioch University. Britney worked in the music industry for several years prior to discovering her calling as a therapist. Britney’s background in music management, gave her first hand experience working with musicians impacted by addiction. Britney specializes in treating trauma using Somatic Experiencing and evidence based practices. Britney’s work begins with forming a strong therapeutic alliance to gain trust and promote change. Britney has given many presentations on somatic therapy in the treatment setting to increase awareness and decrease the stigma of mental health issues. A few years ago, Britney moved into the role of Clinical Director and found her passion in supervising the clinical team. Britney’s unique approach to client care, allows us to access and heal, our most severe cases with compassion and love. Prior to join the Carrara team, Britney was the Clinical Director of a premier luxury treatment facility with 6 residential houses and an outpatient program