The general goal of opioid detoxification is to transition the patient off the opioid humanely, without causing the intense symptoms of stopping the drugs abruptly.
Though not life-threatening, narcotic withdrawal syndrome is very unpleasant and is one of the reasons that addicts seek their drug. The symptoms are basically the reverse of the drug effects: instead of pupillary constriction, the pupils dilate The patient experiences goose flesh (hence the term “going cold turkey”). The constipation of narcotic use is replaced with diarrhea, and the analgesia of narcotis is replaced by diffuse aches and pains.
Opioid Detox, General Approaches
Opioid detoxification can be achieved in either the inpatient or outpatient setting. If inpatient, this is usually achieved over 3 to 10 days. The patient is assessed which includes a full history and physical exam and a treatment plan is devised that fits the patient’s needs, wishes, co-morbidities, and insurance status. If a patient arrives to a clinic or hospital exhibiting symptoms or signs of opioid withdrawal, other causes are ruled out by a careful history, physical examination and targeted laboratory tests.
The general approach to opioid withdrawal is to replace the opiate drug of abuse (heroin, prescription narcotics) with another opiate in a controlled manner in order to halt or minimize symptoms. This replacement opiate will be weaned over time. This varies from patient to patient. Some patients are kept on the opioid agonist (such as methadone or buprenorphine) while they continue non-pharmacologic therapy for prevention of relapse. Other patients are weaned over 7-10 days and the remaining symptoms of withdrawal are managed with non-opioid medications such as those listed in the table above.
Insurance does not typically pay for inpatient opioid detox because it is not life threatening. However, when patients have complicating factors likely medical or psychiatric conditions that will or can destabilize with withdrawal they may warrant inpatient detox. Though opiate withdrawal is generally considered less likely to produce severe morbidity or mortality compared with barbiturates, benzodiazepines, or alcohol, many patients and physicians prefer to utilize medications to manage the symptoms of withdrawal in hopes of improving overall chances of longterm abstinence. The most common symptoms of opioid withdrawal include dysphoria, restlessness, rhinorrhea, lacrimation, myalgias, arthralgias, nausea, vomiting and diarrhea. These symptoms and signs can begin 6 to 12 hours after the last dose of short-acting opioid and 24 to 48 hours after the last dose of long-acting acting opioid.
Methadone and Related Drugs
Methadone, buprenorphine and other non-opioid drugs, such as clonidine, are the most commonly used methods of pharmacologic detoxification.
Methadone is the best studied medication for opioid detox and has been shown to be more effective than alpha-2 agonists for use in the general adult population. It is also effective for opioid withdrawal symptoms in emergency settings. Though little evidence exists for the use of this drug in adolescent populations, methadone is used for medically stable adolescent patients to prevent withdrawal symptoms. The safety of detoxification with methadone in pregnancy is also not well-studied. Though case reports of harm to the fetus have been published, most evidence suggests that there is no increased risk of harm.
Alpha-2 agonists such as clonidine or lofexidine are used suppress autonomically mediated signs and symptoms of abstinence such as tachycardia and tremor. See more below in “Outpatient Pharmacotherapy”
A treatment option called Ultra-rapid Opioid Detoxification (UOD) during which the patient is placed under conscious sedation or general anesthesia and naloxone administered intravenously. This precipitates acute withdrawal while the patient is unconscious. After several hours, the patient wakes up with most of withdrawal finished. This approach is controversial because of the questionable risk benefit ratio of exposing the patient to the effects (and cost) of anesthesia for a non-life threatening condition that can be managed in other safe and relatively inexpensive ways. There is no definitive evidence to suggest that UOD patients experience higher rates of successful recovery.
There are multiple options available for outpatient treatment of opioid dependence detoxifications. Options are based on numerous factors including the substance being used, the length its been used, use of other substances, and co-occurring psychiatric and medical problems. Methadone and buprenorphine are the only opioid medication that is FDA-approved to detox outpatients. Buprenorphine is an opioid partial agonist. At low doses buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms. The agonist effects of buprenorphine increase linearly with increasing doses of the drug until at moderate doses they reach a plateau and no longer continue to increase with further increases in dose (known as the “ceiling effect.”).
Many outpatient detoxification regimens utilize a combination of supportive medications. Clonidine is the most common and helps reduce many of the symptoms associated with withdrawal. It needs to be sufficiently dosed to provide relief of autonomic symptoms while being cautious of over medicating due to its affects on blood pressure. It is dosed until some sedation is felt while maintaining blood pressure of at least 90 to 100 systolic.
Promethazine or other anti-emetics are commonly used to relieve vomiting and severe nausea. Patient will often need this medication in order to continue adequate fluid intake to compensate for vomiting and diarrhea. Imodium is generally effective in standard dosing to alleviate the frequent diarrhea. Hydroxyzine and trazodone are often used to provide some relief of anxiety and insomnia that are both significant during the withdrawal process.
It is impossible to alleviate all withdrawal symptoms. A discuss to provide realistic expectations, while remaining optimistic, is important. The severe withdrawal symptoms of opioids, although not life-threatening, are generally so intolerable that they are the most likely cause to continue use and relapse. Much of the care at this point of treatment is both physical and psychologically supportive.
Behavioral and Social Support
For opiate dependence treatment to be successful, it needs to be followed by ongoing therapy, which may include relapse maintenance therapy. For example, over 90% of heroin addicts will relapse after detoxification if no further treatment given. After patients have completed initial detox, they are strongly encouraged to enter into outpatient treatment program to learn about their disease of addiction and the necessary coping skills needed to remain drug free. They will also obtain the support needed that is not often available from family and friends that do not understand their disease. For some patients, pharmacotherapy to support abstinence and prevent relapse will be used. These programs can last from months to years, depending on the program and the patient’s progress.
Opioid Detox: Conclusions
When your patient becomes convinced of the need to stop using opioids, either street drugs or prescription opioids, the first step will be detoxification. There are several ways this can be done: the choice may depend on the patient’s social support, insurance coverage, and the presence of additional medical or psychiatric problems. It is important for you to know the plans that are developed for your patient by the providers who will oversee the detoxification and subsequent care so that you can support the process as they go through it. This may come in the form of avoiding writing prescriptions for opioids, answering patient’s questions about the drug therapy that was used during their detox or providing ongoing encouragement and assurance to the patient when they question the efficacy of this treatment.