TREATMENT OF OPIATE WITHDRAWAL SYNDROME.

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Opiates cause depression of activity in certain area of the brain and body.When the opiates are no longer present, these areas become hyperactive.  Hyperactivity of the intestinal tract can cause cramping, bloating, diarrhea.Hyperactivity in the in the area of the brain known as the Locus Coereleus (LC) causes a whole host of symptoms as well.There are a number of strategies for the treatment of opiate withdrawal 

One strategy includes treating the symptoms of withdrawal without giving substituting other opiates.  In this case, withdrawal from short acting drugs such as heroin begins in 12 hours, peaks 48-72 hours and has almost completely resolved by 5-7 days.  Of course, the discomfort can be rather intense but there are drugs are available to alleviate the symptoms.  Clonidine is a blood pressure medication that is useful in treating opiate withdrawal.  It can directly lessen the degree of over activity in the LC.  Numerous studies have demonstrated that it reduces the subjective symptoms of withdrawal.  It has side effects such as sedation and low blood pressure.  These can be a problem at times but the side effects can often be minimized by careful dose adjustment.  In addition, there is still a great deal of irritability and insomnia that can be treated with sedatives and sleeping pills.  Aches and pains, nausea, vomiting, diarrhea and cramping can all be treated with commonly available medications. 

Another strategy involves the gradual reduction of opiates so that the intensity of withdrawal never becomes intolerable.  Many programs, both inpatient and outpatient, will substitute a long acting drug, such as Methadone, for the shorter acting drugs which constitute most of the abused opiates.  This results in two benefits.  The course of withdrawal with Methadone is easier to control, as there are fewer variations in drug levels and therefore fewer variations in the intensity of the withdrawal syndrome.  Additionally, the continued use of the drug of choice can be detected, since methadone will show up in drug testing as distinct from other opiates.  That makes it easier to evaluate the success of treatment. 

The problem with methadone is the legal restrictions on its use since it can only be given in a hospital setting or on site at a methadone clinic.  Many private doctors who are trying to perform an outpatient detox prescribe other opiates such as Darvon or Vicodan.  These are widely available but they are short acting.  Therefore, the withdrawal syndrome is more difficult to control and the patient is often under medicated.  In addition, these drugs are also more likely to be abused.  Therefore, the use of these drugs alone is more likely to result in treatment failure.

Buprenorphine has been approved for office based opiod maintenance.  The doctors allowed to prescribe this have to have a special certification and licensure from the DEA and state.  Buprenorphine is a long acting drug like Methadone.  This allows for more control of symptoms.  It is also a safer drug than Methadone and easier to come off of.  However, Methadone is a more powerful medication.

It is important to remember that the use of opiates of any type will prolong the duration of the withdrawal syndrome.  This is because the receptors do not empty of drugs as quickly.  Also, many addicts will want their time on medication prolonged because of fear and because most opiates are inherently addictive.  In my own personal experience, when the duration of the detoxification regimen exceeds some critical time (which varies for each patient), the patient’s motivation to complete the detox regimen is lost and there is a treatment failure.  This is especially true in an outpatient setting.

Traditionally, detoxification has occurred in an inpatient setting.  This is a result of several factors including a reluctance to give a substance abuser addictive medication to take home. There is also a belief that the symptoms of withdrawal are too intense for outpatient detoxification to be of much value.  These concerns are valid and certainly result in treatment failure in some patients.  However, the restrictions placed on treatment providers by the HMO’s are making us rethink outpatient detoxification.  I have developed an experience with thousands of patients undergoing outpatient detoxification of opiates using a combination of the above strategies.  I rely on Clonidine as well as sedatives and other medications.  I have treated persons using more than 25 bags of heroin and others on an excess of 80 pills daily.  I have found that about a third accomplish the detoxification easily and another third complete this with a course marked by temporary relapses.  I will refer the last third to inpatient detoxification if they are not lost to follow-up.  I have found that the most important factors are the desire to get clean as well as the presence of a social support system.

In another article, I will talk about strategies where withdrawal is hastened by the addition of antagonist medication.

 

Stuart Wasser MD