After detox: what comes next

Detox gets you safely through withdrawal. It doesn’t treat the substance use itself. ASAM’s 2020 alcohol guideline says withdrawal management “alone is not an effective treatment for alcohol use disorder,” and its opioid guideline says detox without ongoing treatment is not a treatment for opioid use disorder and is not recommended. The days after you leave are when the next plan matters most, and after opioid detox they’re also when overdose risk is highest.

Why the risk goes up after opioid detox

Withdrawal resets tolerance. A dose your body handled a few weeks ago can now stop your breathing. SAMHSA’s TIP 63 lists using opioids after a period of abstinence, including after medically supervised withdrawal, as an overdose risk, and says people who complete supervised withdrawal are at risk of overdose. It also says most people with opioid use disorder who go through supervised withdrawal start using again and don’t stay in recommended care. That’s not a judgment. It’s the reason the plan after detox matters.

What the research shows:

• In a London study of 137 people after inpatient detox (Strang, BMJ 2003), 3 died of overdose within 4 months. All 3 had completed detox and lost tolerance. The study was small, and the authors said it needed replication.
• Among 40,885 insured US adults with opioid use disorder (Wakeman, JAMA Network Open 2020), only buprenorphine or methadone treatment was linked to lower overdose risk at 3 and 12 months. Inpatient detox or residential services alone were not.
• Among 17,568 Massachusetts overdose survivors (Larochelle, Annals of Internal Medicine 2018), methadone was linked to lower opioid-related death (adjusted hazard ratio 0.41), and so was buprenorphine (0.62). The study found no link for naltrexone, but there were few events to measure.

A 2017 meta-analysis in the BMJ (Sordo) pooled 19 cohort studies. All-cause deaths per 1,000 person-years:

	In treatment	Out of treatment
Methadone	11.3	36.1
Buprenorphine	4.3	9.5

Overdose deaths followed the same pattern: 2.6 versus 12.7 for methadone, and 1.4 versus 4.6 for buprenorphine. The same review found the weeks right after leaving treatment, and the start of methadone, were high-risk periods.

Medication for opioid use disorder

TIP 63 says medications for opioid use disorder lower the risk of overdose death better than placebo or no medication, and that people taking them are considered to be in recovery. There are three: buprenorphine, methadone and naltrexone.

ASAM recommends buprenorphine or methadone over stopping abruptly. The first buprenorphine dose waits for objective signs of withdrawal; opioid withdrawal explains why timing matters with fentanyl. Methadone is given through an opioid treatment program (OTP).

Naltrexone blocks opioids, so it can’t start until you’ve been off short-acting opioids at least 7 days, or long-acting ones 10 to 14 days. That gap makes the handoff from detox the moment to plan for.

Whichever you’re offered, also leave with naloxone. ASAM says it should be provided to anyone being treated for, or with a history of, opioid use disorder. The FDA approved Narcan nasal spray for sale without a prescription on March 29, 2023.

After alcohol detox

ASAM’s alcohol guideline says treatment for alcohol use disorder should start alongside withdrawal management when feasible. For the specific medications and how they compare, see medications for alcohol use disorder on our sibling site, alcohol.help.

If you came off benzodiazepines too, or instead, the 2025 tapering guideline says clinicians should keep checking in for 2 to 4 weeks after the last dose. See benzodiazepine withdrawal.

The treatment gap is wide

In the 2025 National Survey on Drug Use and Health, released July 27, 2026, about 1 in 6 people aged 12 and older who needed substance use treatment (16.0%, or 7.6 million) received it in the past year. Young adults aged 18 to 25 were least likely to get it: 9.6%. SAMHSA presents the treatment-need numbers only for 2025, because the questions changed in 2024, so don’t compare them with older reports.

Being in a detox program is a chance to close that gap for yourself, because the staff can line up the next step before you leave.

What to ask the detox program before you leave

Ask early, ideally on day one, so there’s time to set it up:

• Can I start buprenorphine or methadone here, or get a referral to someone who will continue it?
• For alcohol: can I start a medication for alcohol use disorder before I go?
• Who is my next appointment with, and when? Can you book it now?
• Do you offer, or refer to, residential, intensive outpatient or outpatient treatment?
• Will I leave with naloxone?
• Who do I call if I’m struggling in the first week?
• Will my insurance or Medicaid cover the next step? (See paying for detox.)
• Can my family be part of the discharge plan?

If a program can’t answer these, that tells you something. Look for one that can. Levels of withdrawal care explains the settings, and the finder shows programs near you.

When to call 911

• Someone can’t be woken up, or their breathing is very slow or has stopped. Give naloxone if you have it.
• Someone has a seizure, or becomes confused and disoriented.
• Someone is in immediate danger of harming themselves. For thoughts of suicide without immediate danger, call or text 988.

Before you’re discharged

Get a date and time for your next appointment in writing, and naloxone in your bag if opioids were involved. If you’ve already left without a plan, call today: SAMHSA’s National Helpline, 1-800-662-4357 (free, 24/7), refers callers to local treatment.

Sources

• ASAM, The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management, J Addict Med, 2020 (adopted Jan 23, 2020)
• ASAM, The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update, J Addict Med, released Mar 2020
• SAMHSA, TIP 63: Medications for Opioid Use Disorder, 2018 edition
• SAMHSA, Quick Guide for Clinicians Based on TIP 45: Detoxification and Substance Abuse Treatment, based on TIP 45 (2006)
• Strang J, et al. Loss of tolerance and overdose mortality after inpatient opiate detoxification, BMJ, May 3, 2003
• Wakeman SE, et al. Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder, JAMA Netw Open, Feb 2020
• Larochelle MR, et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality, Ann Intern Med, Aug 7, 2018
• Sordo L, et al. Mortality risk during and after opioid substitution treatment, BMJ, Apr 26, 2017
• FDA, FDA Approves First Over-the-Counter Naloxone Nasal Spray, Mar 29, 2023
• Brunner E, et al. Joint Clinical Practice Guideline on Benzodiazepine Tapering, J Gen Intern Med, 2025 (epub Jun 17, 2025)
• SAMHSA, Highlights for the 2025 National Survey on Drug Use and Health, released Jul 27, 2026
• SAMHSA National Helpline, last updated Jun 9, 2023