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At the heart of general practice since 1960

September 2007: Offer detoxification as a treatment option for opioid misuse

Who is at risk of misusing drugs?

What are the treatment options?

How should long-term misuse be managed?

Who is at risk of misusing drugs?

What are the treatment options?

How should long-term misuse be managed?

Drug misuse is a common problem that impacts on every section of society, causing significant harm to individuals, their families and the community. In the UK, an estimated four million people use illicit drugs each year. Approximately 50,000 people misuse opioids,1 and more than 150,000 people are in treatment for opioid misuse.2,3

Given the complexity and high prevalence of drug misuse, it is timely that NICE has published evidence-based guidance on two aspects of treatment: detoxification and psychosocial interventions4,5 However, it is important that by focusing on detoxification the guidelines do not in any way detract from, or undermine, the significant success associated with maintenance pharmacotherapies.

Drug misuse, in particular heroin and cocaine misuse, affects patients' mental, physical and social functioning (see table 1,attached). Drug misusers who inject are most at risk because of the risks posed by needle sharing (for example infection with hepatitis C or B or HIV), the risk of overdose (accidental or intentional) and the harm associated with funding a habit, for example sexually transmitted infections and involvement in criminal activities.

There is no single risk factor that predicts whether an individual is likely to misuse drugs. A number of complex social factors are involved, interwoven with the availability and price of the drug, the culture and the effects that the drug produces (see table 2,attached). There is no evidence to support a progression from soft to hard drugs.

Once an individual is dependent, drug misuse is likely to become chronic, interspersed with periods of relapse and remission. It may take many attempts to become abstinent; many individuals who commence their habit in their late teens or early twenties continue for two, three or even four decades. Repeated involvement with the criminal justice system, long-term unemployment and increasing social isolation entrenches drug using behaviour, and strategies for this group are likely to be different from those for new, experimental drug misusers.

Treatment

No single treatment is appropriate for all patients. Substitute medication, such as methadone or buprenorphine, is an important element of treatment in most cases.

41144901The general principles of treatment are set out in table 3, above.

The main aims of treatment include:

• Management of withdrawal symptoms

• Reduction of physical, social and psychological harm to the patient and the public

• Prevention of relapse and maintenance of abstinence

• Prevention of complications of substance misuse, for example advice around safer injecting practice and provision of hepatitis B testing and immunisation.

Methadone maintenance

Methadone is the most established treatment option for heroin or other opioid dependence and is used in many countries.6,7 Many studies, several of which were double-blind placebo-controlled trials,8 have demonstrated that long-term treatment with methadone (and increasingly buprenorphine) can significantly reduce levels of illicit drug use, crime, injecting and other risk behaviours and drug-related death. It can also improve quality of life, health and increase sense of wellbeing.

Detoxification

Notwithstanding the benefits of maintenance treatment, detoxification has a place in the treatment armoury for opioid addiction. Detoxification is defined as a process whereby the individual is supported, with the use of pharmacological and psychosocial interventions, to reduce their use of illicit opioids gradually, over a period of days, weeks or up to three months.

The recommendations for residential detoxification include those patients with complex medical or social problems; patients who are alcohol and drug dependent; patients who are young and have a shorter history of dependence, where it may well be better to try residential treatment early on in their drug taking career; and also patients who have failed community attempts on a number of occasions.

NICE recommendations

For all patients who are dependent on opioids and have expressed an informed choice to become abstinent, services should:

• Offer detoxification as a readily available and effective treatment option

41144902• Provide detailed information about detoxification and the associated risks, including:

– The physical and psychological aspects of opioid withdrawal and the duration and intensity of symptoms (see table 4,above)

– How such symptoms may be managed (see table 5,attached)

– The loss of opioid tolerance after detoxification and the ensuing increased risk of overdose and death from illicit drug use

– The importance of continued support, as well as psychosocial and appropriate pharmacological interventions, to maintain abstinence, treat comorbid mental health problems and reduce the risk of serious adverse events

• Offer community-based detoxification programmes routinely, except to individuals who:

– Have not benefited from previous community-based detoxification. If patients have relapsed after a community detoxification it might be worth considering inpatient supported detoxification as this will be able to provide more monitoring, supervision and support

– Need medical and/or nursing care because of significant coexisting problems

– Require complex polydrug detoxification, for example patients with concurrent alcohol or benzodiazepine dependence

– Are experiencing considerable social problems that may substantially limit the benefit of a community detoxification programme

Pharmacological interventions

The mainstays of pharmacological treatment for opioid dependence are methadone and buprenorphine (see table 6, attached). These medications block opioid receptors, allowing the individual to be free from the effects of opioid withdrawal.

Patients may stay on opioid substitution treatment for many years before deciding to attempt detoxification and become abstinent from both illegally obtained and prescribed opioids.

GPs are well placed to offer both maintenance and detoxification opioid substitution therapies. However, GPs should work within a multidisciplinary framework, as drug misusers have many needs that will benefit from the expert intervention of different professional groups.

Psychosocial interventions

There is overwhelming evidence from the US and Europe supporting the efficacy of contingency management as part of a planned implementation programme to reduce illicit drug use and/or promote engagement with services for people in maintenance programmes.4 It is unlikely that contingency management will be carried out in primary care.

The process involves providing incentives, such as vouchers or privileges, contingent on each presentation of a negative drug test result. Vouchers can be exchanged for goods or services, for example food, and privileges increase the patient's choice (for example, use of take-home methadone doses).

Incentives may also be used for those at risk of comorbidity from drug misuse, contingent on concordance with specific harm reduction activities, particularly for completion of hepatitis B immunisation.

Conclusion

At the time of writing, the DH's drug misuse guidelines ("the Orange Book")9 are being revised. It is likely that the guidelines will reinforce the NICE recommendations.

Evidence on detoxification makes it clear that abstinence (as opposed to harm reduction) is an effective treatment option and that psychosocial interventions for drug misuse, though not well developed in the UK, can bring real benefits.

Opioidmisusetab3 opioidmisusetab4 Key points Table 1: Risks associated with heroin use Table 2: Predictors of drug initiation in adolescence Table 5: Management of symptoms of opioid withdrawal Table 6: NICE recommendations for pharmacological interventions Useful information

The RCGP Certificate in Substance Misuse can provide GPs with additional training in substance misuse.
www.rcgp.org.uk

Author

Dr Clare Gerada
FRCGP MRCPsych
GP, South London, and Chair of the NICE Guideline Development Group on Detoxification

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