Download Drug Detoxification revisited

Drug Detoxification revisited
 Dr Lucy Cockayne
 Consultant Psychiatrist
 NHS Lanarkshire
Drug Detoxification Revisited
 Why detox and why NOT to detox?
 When to detox.
 How to detox. – the old and the new.
 What is a successful detox?
Choosing the right detox
“there are a multitude of treatment
approaches to choose from: outpatient,
inpatient, 12-step, group therapy, and
the list goes on.”
“An individual can become thoroughly confused by asking a
half-dozen recovering alcoholics or drug addicts how they
ended their use of alcohol or drugs; the answers vary
although each of them may seem convincing and emotional.
They will cite such diverse approaches as hospitalization,
diet, exercise, counselling, sauna's, religion, hypnosis, amino
acids and self-help groups.
When it comes to successful treatment, only one thing is
certain: practically any approach will work for some of the
people, some of the time.”
To put it another way, successful treatment is
like a designer suit- it's got to be tailor-made for
each individual.
Who chooses?
“all too often the detoxification process is
‘prescriber/cost/locality’ centred rather than
client centred…. Directed to the treatment
prescribing services’ preferred modal,
irrespective of whether it is the most
appropriate for that individual”
T.S.Johnson, Addiction Biology 2003
Current situation in Scotland –
a personal view
 Postcode lottery
 Little choice in detoxification options
 Patchy post detox support
 User suspicion of social service support – a
reluctance to be referred.
Opiate detox – the options
 Broadly three types of detox:

Tapering eg methadone reduction

Transitional/substitution eg subutex/lofexidine

Rapid opiate withdrawal using naltrexone
Ultra- rapid opiate detox
 3 decades of experience
 Aim is to increase compfort during withdrawal
 Little NHS use currently
 Recent moves from simply detox to NIMROD-
i.e.induction onto naltrexone
From UROD to NIMROD
 Various methods: varying from

Using anaesthesia (UROD)



Asturian technique



Takes as little as 4 hours
Risks of anaesthesia (some deaths)
6-12 hours
Using sedation and early naltrexone challenge
5 day detox

Variety of sedatives and side effect medications
 “test doses” of naltrexone followed by regular oral naltrexone
 Up to 98% opiate free at the end of the procedure
Subutex – a difference in
pharmacology
Heroin/methadone – full effect
Gives a big buzz
Leads to greater potential for dependence
High risk fatal overdose
m receptors
neurotransmission
effect
Subutex – half and half
Helps the user feel comfortable without giving a buzz
Less likely to overdose
Blocks the effects of “on top” use
Blocks full
agonists
m receptors
neurotransmission
effect
Naloxone/naltrexone - blocker
Blocks both
partial and full
agonists
m receptors
No neurotransmission
No effect
Blocks only
Can be used to maintain abstinence
No potential for respiratory depression
Subutex vs lofexidine
White R et al. Drug Alcohol Depend 2001; 65: 77-83
100
% patients completing detoxification
Subutex =
 Higher completion
rate
 Less severe
withdrawal
syndrome
80
Two
thirds
n = 69
P = 0.04
One
third
60
40
20
0
Subutex
lofexidine
After detox…..
 No matter what detox, the risks of relapse are
similar – about 90% in first 12 months.
 Few engage with post detox support… but
here is one:
 Maintenance with ANTAGONISTS – ie
naltrexone – worth a second look?
Naltrexone
 Currently available on NHS as oral treatment.
 Opiate antagonist: blocks μ receptors.
 “Therapeutic” blood levels of 2ng/ml override
high dose diamorphine.
 Shown to be very successful in treating highly
motivated patients (Washton, 1984).
Problems with oral naltrexone
 Washout period required before initiation of
treatment.
 Treatment must last at least 12 months.
 Compliance is poor due to:



Possible adverse effects e.g.dysphoria
Absence of opiate induced reinforcement
No adverse effects on treatment withdrawal
Improving compliance
 Entrusting administration to a relative or carer
(Anton, 1981)
 Contingency contracting (Preston, 1999)
 Naltrexone administered by probation officers
(Cornish, 1997)
Chan and Cornish Papers
 Chan 1996 Singapore



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Highly structure jail release programme
NTX 3x weekly 100:100:150
75% compliance at 12 months on NTX
25% not on NTX
 Cornish et al 1997 USA


twice weekly doses - M100:F150
NTX halved re-offending
Implants- new boy on the block
1.
slow release naltrexone implants
1.
2.
2.
6 week (Wedgewood “Marlburg”)
3 - 12 month (O’Neil)
device NOT licensed for humans:
No prospect of USA licence.
O’Neil licence procedure ongoing
Overview of research on implants
 Impact on accidental overdose in ‘high risk
adolescent heroin users (Hulse 2003)




report that ~600 clients have had O’ Neil implants
inserted since August 2000
Looks at effects of implant on 8 ‘high risk’ adolescents
“results indicate a dramatic reduction in overdose”
following implant
“study design does not allow causality to be imputed
Cont..
 Prevention of early relapse (Foster et al 2003)
 looks at 2 cohorts of patients with 6 week implant
 1st cohort 55, 2nd cohort 46
 At 12 weeks 21-26% resumed opiate use
 30% tested out blockade
 blood levels at 4-5 weeks were 3-5ng/ml
 this level blocks 500mg diamorphine
 “troublesome tissue reactions infrequent”
Cont...
 NTX implant as maintenance treatment (Carreno et al
2003)



156 patients on maintenance antagonist using
implant for 1 year with 1 year follow up
retention 80% at 6 months, 65% at 12 months
at 18 months 55.4% in contact ALL opiate free
(20.8% at 24 months)
UK Evidence: Stapleford study
 150 consecutive patients
 6 week naltrexone implants - two year period,
 opiate-free:- 100% at 5 weeks
 Re-implantation:-
(Brewer, 1999).
80% at 3 months
60% at 6 months
41% second implant
18% third implant
13% fourth implant
5% fifth implant
Potential problems with implants
 Psychological



“wonder cure”
coping with being drug free
taking away freedom of choice
 Physical


implant site - reactions
trying to over-ride implant
Taking implants forward in the UK
 As unlicenced only appropriate in a research
setting
 Several trials being proposed – but problems
with indemnity…
 WATCH THIS SPACE….