Withdrawal

Regular users of opioids who are withdrawing may experience a range of symptoms including:

• agitation

• muscle aches

• sweating

• diarrhoea and vomiting. 

Signs include dilated pupils.

Detoxification in heroin addiction

A 27-year-old patient with known heroin addiction on methadone maintenance therapy is ready for complete abstinence from all opioids. He is being considered for detoxification therapy.

A. Detoxification should be avoided

B. Detoxification should be performed using buprenorphine

C. Maintenance therapy should be continued

D. Review in one month

E. Detoxification should be performed using methadone

If a patient is ready for complete abstinence from all opioids they can undergo detoxification. If a patient is new to treatment, they can be offered a choice between buprenorphine and methadone detoxification. If the patient has been receiving methadone or buprenorphine as maintenance therapy, then current guidance states that detoxification should usually be performed using the same medication.

Resource:

• Doan L. Substitute prescribing in heroin addiction. InnovAiT 2019; 12(11): 664–671.

According to the National Institute for Health and Care Excellence (NICE), opioid detoxification should be a readily available option for people who are opioid dependent and have expressed an informed choice to become abstinent. Assessment of an individual for detoxification should be made according to NICE guidelines.

Methadone or buprenorphine should be offered as first-line treatment. Detoxification should normally be started with the same medication as used for any maintenance treatment, taking into account the preference of the service user. Dosages and duration of treatment are discussed in the NICE guideline with detoxification normally lasting up to four weeks in an inpatient/residential setting and up to 12 weeks in the community.

Clonidine or dihydrocodeine are not used routinely in opioid detoxification.

Lofexidine may be considered for those who do not want to use methadone or buprenorphine for detoxification or for those with mild or uncertain dependence. Lofexidine is sometimes used to detoxify individuals within a shorter time period.

Naltrexone can be used as an adjunct to prevent relapse in detoxified formerly opioid-dependent patients who have remained opioid free for at least 7–10 days. Close supervision is required.

Resources:

NICE. Drug Misuse in Over 16s: opioid detoxification. CG52. 2007.

RCGP. Curriculum Topic Guides: smoking, alcohol and substance misuse. 2019

Opioid users who are treated with methadone or buprenorphine are at an increased mortality risk in the month immediately following cessation of treatment, compared to when they are established in treatment. 

A 2020 study led by Royal College of Surgeons in Ireland (RCSI) researchers indicated that the rate of drug-related deaths was more than four times higher in the month following the end of treatment and over three times higher in the first four weeks of treatment when compared to the remaining time in treatment. These findings are consistent with growing evidence from other international studies.

It is speculated that if they return to opioid use following cessation, then they may have lost tolerance and be more vulnerable to overdose.

Resource:

Durand L, O'Driscoll D, Boland F, et al. Do interruptions to the continuity of methadone maintenance treatment in specialist addiction settings increase the risk of drug-related poisoning deaths? A retrospective cohort study.  Addiction 2020; 115(10): 1867–1877. 

Opioid users have about ten times the risk of death compared to the general population. Most of these deaths are due to overdose.

Methadone therapy

Which is the SINGLE MOST likely benefit of methadone therapy compared with treatments that do not involve opioid replacement therapy? 

1. Reduced unemployment

2. Reduced hospital admission

3. Reduced A&E attendance

4. Reduced GP consultations

5. Reduced heroin use

In a 2009 Cochrane review of management of opioid dependence, treatment with methadone was shown to be effective in retaining patients in treatment and suppressing heroin use. There was no reduction in criminal behaviour or mortality. However, other studies have shown that methadone reduces mortality by approximately 50% in patients with an opioid use disorder. Risk of HIV infection is also reduced in injecting drug users.

Resource:

• Mattick R, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Library 2009; 3

Neonatal abstinence syndrome

A young woman, on methadone maintenance, delivers a 3500g baby and discharges herself from hospital after 24 hours. She is breastfeeding. On the third day postnatally, she phones and tells you the baby seems very irritable, has a high pitched cry and is breathing very rapidly. You visit them.

Which of the following actions is the SINGLE MOST appropriate? 

Admit the baby to hospital with the mother

The baby is likely to be suffering from neonatal abstinence syndrome due to methadone withdrawal and would most safely be cared for in a paediatric unit. The mother should be encouraged to continue to take her usual dose of methadone. She should also continue to breastfeed as the small amounts of drug in her breast milk will help the gradual reduction of methadone levels in the baby’s blood.

The mother is likely to have high levels of guilt and discussing these with a counsellor or health visitor, at a later point, would be therapeutic.