Download Practice Guideline Summary for Opiate Detoxification

MHNet Behavioral Health
PRA CT IC E GU ID EL IN E FOR O PIAT E WIT HDR AWAL
MHNet monitors practitioner’s adherence to the following elements in the
treatment of Substance Use Disorders:
•
Appropriate Use of Detoxification Medications
•
Appropriate Vital Signs Monitoring During Detoxification
Substance abuse and dependence are endemic in the population affecting as
much as 10% of adults. Substance abuse costs society billions of dollars in lost
revenue and medical expenses. Alcohol and nicotine dependence represent the
vast majority of substance abuse. However opiate dependence, both licit
(prescription) and illicit (heroin and other street drugs) continues to be a
significant problem.
The treatment of substance abuse requires:
•
routine screening of all individuals with behavioral, medical and social
problems;
•
comprehensive assessment of patients suspected of substance
abuse;
•
medical management of intoxication and withdrawal;
•
development of an individualized treatment plan which acknowledges
the chronicity of substance abuse; and
•
ongoing care, making use of the full spectrum of community support.
Background
Detoxification from opiates can be accomplished on an inpatient or outpatient
basis using decreasing doses of orally active opiates, with the mixed opiate
agonist/antagonist buprenorphine or with the α2 adrenergic antagonist,
clonidine. Regardless of which agent is used, severe withdrawal symptoms
usually last 72 hours or less. Residual withdrawal symptoms may continue for
days or even weeks.
After detoxification all patients should receive ongoing treatment to maintain
abstinence. Many clinicians recommend that abstinence be associated with
daily administration of an orally active opiate blocking agent (naltrexone, ReVia
®). Patients who take naltrexone will experience no effects from opiates.
Unfortunately, since naltrexone is only effective for 1-3 days, any individual who
wishes to abuse opiates can skip a few doses and thereby experience the full
effect of opiates.
Detoxification
The majority of detoxified patients (70%-80%) relapse to opiates within a year.
Some clinicians have suggested that the relapse rate can be decreased by
rapidly completing the detoxification process and rapidly initiating naltrexone
therapy. This belief has spurred the use of ultra-rapid (anesthesia assisted)
opiate detoxification. The procedure involves anesthetizing and paralysizing the
patient. A parenteral opiate blocking agent is then administered resulting in
immediate and severe withdrawal symptoms. Once the symptoms abate
naltrexone can be administered through a naso-gastric tube. The patient is then
awakened free from withdrawal symptoms with sufficient naltrexone in their
system to block the effects of opiates for at least 24 hours.
In the past opiate withdrawal has been managed by using decreasing doses of a
long-acting orally active opiate. However with increasing emphasis on early
abstinence, the use of clonodine to manage withdrawal symptoms has become
increasingly popular. Management of other opiate withdrawal conditions is
symptom specific.
Anxiety can be managed with reassurance and
benzodiazepines, if necessary. Aches and pains can be managed with nonopiate analgesics. Cramps and diarrhea can be managed with routine
medications for GI distress.
In the past few years the FDA has approved a new agent (buprenorphine,
Suboxone®, Subutex®) for opiate withdrawal as well as maintenance treatment
for opiate abstinence. Physicians wishing to use buprenorphine must receive a
waiver and a unique DEA number from the FDD to prescribe buprenorphine.
The FDA provides a buprenorphine specific DEA number based on the
physician demonstrating competence in the use of the drug as well as the
overall
treatment
of
opiate
dependent
individuals
(http://www.buprenorphine.samhsa.gov).
POLICY
MHNet will authorize inpatient or outpatient treatment of opiate withdrawal using
clonidine, buprenorphine or methadone. Inpatient withdrawal should be
restricted to those individuals experiencing severe withdrawal or with co-morbid
conditions that preclude outpatient treatment. Every individual who undergoes
opiate withdrawal should be referred to rehabilitation treatment within three days
of completing detoxification.
MHNet will not approve any form of detoxification using parenteral opiate
blocking agents. In addition, MHNet will not approve the use of any protocol
that involves the use of orally active blocking agents unless those agents are
administered at a time when the risk of precipitating significant withdrawal is
minimal (i.e. after several days of buprenorphine, or clonidine therapy or after
being off methadone for at least a week).
REFERENCES
Fiellin DA, O’Connor PG: Office-Based Treatment of Opiate-Dependent
Patients. NEJM. 2002; 347:817-823.
Collins ED, Kleber HD, Whittington RA, Heitler NE: Anesthesia-assisted vs
buprenorphine-assietd or clonidine-assisted heroin detoxification and naltrexone
induction. JAMA. 2005;294:903-913.
Ultra-rapid opiate detoxification was addressed by MHNet in the Fall of 1998 as
part of a new technology review. It was determined that the literature did not
support the efficacy nor safety of the procedure.
The issue of ultra-rapid opiate detoxification was recently addressed in a study
published in an August 2005 issue of JAMA. The authors randomly assigned
patients to anesthesia assisted detoxification, burpenorphine induction followed
by naltrexone or clonidine assisted withdrawal. The long-term outcome was no
different in the three groups. However the anesthesia assisted group (35
patients) had 3 severe, potentially life threatening complications. Therefore the
authors determined that there is no superiority to ultra-rapid detoxification and
there is significant increased morbidity associated with the procedure.
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