Download opiod detoxification guidelines - Worcestershire Health and Care

WORCESTERSHIRE MENTAL HEALTH
PARTNERSHIP NHS TRUST
OPIOD DETOXIFICATION GUIDELINES
This policy should be read in conjunction with
This policy should be read in conjunction with the Prescribing Guidelines for
Substance Misuse
Worcestershire Mental Health Partnership NHS Trust Policy Data
Unique Identifier: CP0088
Ratified by: Governance Committee
Ratification Date: 22nd September 2008
Review Interval: Three Years
Version Update:
Review Date: September 2011
Owner: Chief Operating Officer
Reviewer: SMS Consultant Psychiatrist et al
Responsible Forum: Clinical Effectiveness Group
Document Type: Clinical Policy
Superseded Policy:
Search Criteria
If printed, copied or otherwise transferred from its originating electronic file,
this document must be considered to be an uncontrolled copy.
When documents are updated, notification will be circulated throughout the
organisation. Policy amendments may occur at any time and you should
always consult the PDF file held on the Trust’s Intranet.
CONTENTS
1
Background
2
Detoxification period
3
Preparation
4
Families & Carers
5
Assessment
6
Cautions
7
Risk Assessment
8
Setting
9
Method of detoxification
10
Simple of symptomatic relief
11
Detoxification Procedure
12
Lofexidine Detoxification
13
Buprenorphine Detoxification
14
Methadone Detoxification
15
Relapse Prevention (Naltrexone)
16
Naloxone Challenge test
17
Appendix 1
18
Appendix 2
19
Appendix 3
20
Appendix 4
21
Flow chart
22
Useful References
1
1
Background
This guideline outlines the care and treatment of service users who are wishing to undergo
detoxification for opioid dependence arising from the misuse of illicit substances. It covers the
opioid detoxification in community and in-patient settings, and will refer to misuse of other
drugs such as alcohol, stimulants and benzodiazepines only in context of opioid detoxification.
Detoxification is part of the treatment process in the service users’ journey of addiction. Opioid
misuse and dependence is a chronic relapsing and remitting condition, and detoxification
underpins the long term goal of abstinence which is not always achieved.
Opioid detoxification is a clearly defined process supporting safe and effective discontinuation
of opiates while minimising withdrawal symptoms. Pharmacological approaches are primary
option for detoxification, with psychosocial interventions it could lead to an effective outcome
with longer abstinence periods. Review and support for physical and mental health is essential
during this process. Detoxification should be routinely available as one of the treatment options
for service users who identify it as a feature of their long term care plan.
Service users’ needs and preferences should be a key feature of the planning of treatment and
care. Service users should be allowed to make informed decisions and staff should work in
partnership with them to enhance their insight into the treatment process, advantages,
disadvantages and adverse effects. Keyworking is paramount in this process and also
essential to communicate and co-ordinate the care plan with staff providing psycho-social
interventions like Turning Point and Community Rehabilitation.
For a detoxification to be successful it is crucial to involve the patient in its planning and
implementation. It is also important for the patient to have clear ideas and plans in place to
occupy their time after detoxification (once abstinence is achieved) –i.e. getting into
training/employment, identifying structured and constructive activities, developing a ‘non-using’
support network, etc. Research has identified the following predictors of successful
detoxification:
ƒ Good engagement in treatment
ƒ High levels of motivation
ƒ Actual attempts rather than mere ideas to address related problems
This guideline should be read in conjunction with the references listed at the end of this
document.
2
2
Detoxification period
There are different opinions from various literatures available. Some evidence that
detoxification should be a process of achieving a rapid drug free state, and normally takes 10
to 28 days depending on each case. It is different to a slow reduction programme and
detoxification requires good preparatory and after care work. But NICE guidelines and NTA
Orange Guideline 2007 have suggested for in-patient detoxification up to 4 weeks and up to 12
weeks in a community setting. Again it should be service user led and the duration should be
decided on case by case basis.
3
Preparation
When a service user expresses an interest in detoxification, it should be discussed in
referrals/team meeting. Service users could be from prescribing service or from Turning Point.
If referral considered the keyworker within prescribing service (Secondary/Primary/DIP) with
service user’s agreement and informed choice will need to liaise with care co-ordinator/staff
from Turning point and Community Rehab to co-ordinate a series of discussions/contact with
the service user to enable them to make an informed choice to become abstinent and also to
look at after care arrangements following the detoxification period. The detail of these
discussions will need to be outlined in a care plan and in care co-ordination arrangements.
To obtain informed consent following information on detoxification should be discussed:
ƒ physical and psychological symptoms of opiate withdrawal
ƒ duration and severity of symptoms and its management
ƒ use of pharmacological and non-pharmacological approaches in the
management
ƒ loss of opioid tolerance and risk of following overdose and death from illicit
substance use along with alcohol or benzodiazepines
ƒ comorbid mental health and physical health problems
ƒ importance of continued engagement with services for psychosocial and
appropriate pharmacological interventions to maintain abstinence and to
address the risk of adverse outcomes
ƒ need for changes in certain aspects of lifestyle like balanced diet, adequate
hydration, sleep hygiene, regular physical exercise and other activities
3
ƒ information about self-help groups (such as SURGE, 12-step groups, etc.) and
facilitate engagement with such groups
ƒ service user’s anxieties surrounding the detox should be addressed prior to
the program
Use Appendix 1, 2 and 4 in your discussion with service users.
Following the detailed discussion with service user and working in partnership with Care Coordinator, Turning Point, Community Rehab an agreed care plan should be developed. Staff
should establish and sustain a respectful and supportive relationship, help service user to
identify situations or states when he or she is vulnerable to drug misuse. Alternative coping
strategies should be explored with access to wide range of services for support. Importance of
engagement with services following detoxification should be stressed and detailed in the care
plan. It is essential to maintain an effective care co-ordination and collaboration with all care
providers.
Service users receiving substitute maintenance treatment in the service should receive regular
reviews of their care plan and detoxification option should be considered, discussed and
documented.
Service users who are considering detoxification on their own without support from services
should be given information as above and should be strongly advised for detoxification in a
structured treatment program. Also engagement with services during self detoxification and for
after care should be emphasised.
Service users should be encouraged to involve families and carers during the assessment and
treatment plans. Service users should be made aware of their right to confidentiality and their
informed decision should be respected.
During the preparation process for detoxification program, the following challenging points
should be addressed:
ƒ coping skills to deal with detoxification program and strategies to maintain
abstinence
ƒ motivation and readiness for detoxification program
ƒ service users expectations and acknowledgement of positive outcomes
ƒ support network during and after detoxification program
ƒ care plan aiming at relapse prevention
4
ƒ risk assessment ex. Low tolerance and accidental overdose post detoxification
ƒ lessons learnt from previous treatments, detoxifications and rehab programs
ƒ methods of detoxification, choice of medication
ƒ setting or location of detoxification (in-patient or community detox)
Use Appendix 1, 2, and 4 in your discussions/keyworking sessions with service users.
4
Support for families and carers
It is equally important to discuss with families and carers about their concerns, impact of
substance misuse on themselves and other family members, including children. Their personal,
social and mental health needs should be discussed and guidance given about services
available locally such as SURGE, Pressure Point and Turning Point Family Services.
Information about detoxification, settings, self-help and support groups should be provided.
5
Assessment: should include:
ƒ severity of opioid dependence (see Appendix 1 & 2)
ƒ misuse and dependence on other substances
ƒ urinalysis / oral fluid / breath testing to aid identification
ƒ signs of opioid withdrawal
ƒ history of treatment episodes and past detoxifications/rehabilitation programs
ƒ possible complications during detox program - physical and mental health
problems and their treatment
ƒ risks of self harm, suicide or violence possible due to relapse of underlying
mental health problems
ƒ loss of tolerance and misuse of drugs or alcohol as a response to opioid
withdrawal symptoms
ƒ social and personal circumstances, including employment, financial situation,
living arrangements, social support and criminal activity
ƒ risk of relapse, support network, impact on families and carers
Use Appendix 1, 2, and 4 in your discussions/keyworking sessions with service users.
5
6
Cautions
a
detoxification should not be routinely offered for service users in the following
circumstances:
ƒ suffering with physical health problems and in need of emergency treatment
ƒ service users who could only engage or access services for relatively short
period of time (like chaotic lifestyle, accommodation issues, police custody,
refusal to engage with services, short period of sentences)
ƒ not stabilised on current substitute maintenance treatment, chaotic
polysubstance use
ƒ presenting with emergencies at acute hospitals where primary medical
condition should be managed with referral to substance misuse services
ƒ not currently in structured prescribed treatment, unless there were compelling
reasons for detoxification along with a good support network
b
If service user is suffering with alcohol problems along with opioid dependence, should be
encouraged and facilitated to address it as the risk of increased use of alcohol in place of
opioids. If alcohol dependent, alcohol detoxification should be completed before opioid
detoxification in the community or both detoxifications could be done in an in-patient
setting.
c
If service user is suffering with benzodiazepine problems along with opioid dependence,
benzodiazepine detoxification should be completed. It should be discussed with service
users their choice of completing the detoxifications together or separately and also severity
of dependence for both substances
7
Risk assessment
A proper understanding and interpretation of risk involves knowledge of specific withdrawal
syndromes of different substances and interaction with any prescribed medications, the
physical and mental health of service user.
a
Risks associated with withdrawal from substances
ƒ History of seizures
ƒ History of delirium
6
ƒ High severity of dependence and dose of substance particularly short acting
drugs
ƒ Poly drug use (like alcohol, benzodiazepines)
ƒ Poly pharmacy (psychiatric medications, tranquilisers etc)
b
Risks associated with health conditions
ƒ Ischemic heart conditions
ƒ Hypertensive heart disease
ƒ Elderly and serious physical health problems
ƒ Liver, renal problems
ƒ Diabetes, epilepsy, asthma
ƒ Head injury, organic brain damage
ƒ Pregnancy
ƒ Mental health problems
c
Risks associated with support network
ƒ Lack of people support to help cope with the detoxification program and
abstinence maintenance
ƒ Difficulties with child care
Risks should be assessed through out the period of detoxification and there should be raised
awareness of unexpected problems which may arise after all the thorough planning and
delivery of the program. Service users should be made aware of the risks of worsening
physical or mental health problems masked by substance misuse and importance of engaging
and keeping appointments with specialist clinic. Service users should be advised to notify the
services at the onset of prodromal symptoms to prevent relapse of the condition.
8
Setting
a
Service users should be offered routinely community based detoxification program.
b
In-patient detoxification could be considered for those service users who:
7
ƒ Previous failed community detoxification
ƒ Significant medical or mental health problems
ƒ Requiring multiple polydrug detoxification
ƒ Significant social problems
ƒ Service users showing sufficient insight to know that other options are unlikely
to be effective
9
Methods of detoxification
The choice of pharmacological intervention in opioid detoxification to help service users cope
with opioid withdrawal syndrome should be an informed decision. Generally service users
should be made aware that detoxification program would help them to minimise the
physiological and psychological opioid withdrawal syndrome and also that some discomfort are
inevitable as all signs and symptoms are rarely controlled.
NICE and NTA 2007 guidelines suggests that when deciding between different
pharmacological interventions, following issues should taken into consideration:
ƒ Opioid detoxification should normally be started with same medication with
which service user was on maintenance treatment and was stabilised
ƒ Service users should be provided with all the information and it should be their
preference and clinically appropriate decision
ƒ Clonidine and dihydrocodeine should not be used routinely in opioid
detoxification
10
Simple symptomatic relief
This regime is suitable for those service users who have features of no or mild opiate
dependence with current low level use of heroin (below 0.5 gram daily), preferably with short
history (maximum 18 months) of use. And also service users showing good motivation to
remain abstinent from opioids use.
Contra-indications
ƒ Pregnancy
ƒ Injecting 0.2g or above of heroin daily
8
ƒ Heroin use for over 18 months (unless only has features of mild dependence,
and low level of use – that is, smoking less than 0.5g daily)
ƒ Poly drug use and/or alcohol misuse
ƒ Severe mental and/or physical illness
Detoxification Procedure
Reduce current use before detoxification – ideally to 0.25g heroin daily.
Before commencing symptomatic detoxification, discuss possible use of Lofexidine.
If detoxification is in the Community commence programme Monday or Tuesday with frequent
monitoring during the week.
Zopiclone 7.5mg to 15mg nocte may be prescribed to help with insomnia. Difficulty sleeping is
one of the commonest complaints and medications can only usually help to a limited extent.
Time limited prescription for 2 to 4 weeks should be more than sufficient.
Problems with anxiety is quite challenging and can be an important management problem
during detoxification. Evidence suggests that good informed discussion during the preparation
process for detoxification program can significantly help to reduce this along with reassurance
techniques and psychosocial interventions are an important adjunct for successful outcome.
Short duration prescriptions of small doses of long acting benzodiazepines (chlordiazepoxide
or diazepam 2-5mg tds) may be useful, but should be used cautiously because of high
addiction potential. Other alternative could include promazine 25mg tds (and 50mg nocte).
Ibuprofen 200-400mg tds or Diclofenac 75mg bd, for muscle ache. Topical preparations may
be useful in some people. Service users should be advised not to use these medication in
empty stomach because of the risk of gastritis and stomach mucosal ulceration.
Loperamide 4mg initially, and 2mg after each loose stool (max 16mg per day) for diarrhoea.
Metoclopramide 10mg tds PRN for nausea and vomiting.
Buscopan 10mg tds PRN for stomach cramps.
11
Lofexidine detoxification
Lofexidine is centrally acting adrenergic agonist and indicated in management of symptoms of
opioid withdrawal.
9
Pharmacology
Lofexidine is an alpha-2 agonist. Agonistic activity at alpha-2 receptor provides negative
feedback to descending sympathetic nerves controlling production of catecholamines and
helps to control adrenergic symptoms of opioid withdrawal. It has no opioid activity, very low
misuse potential and no issue of diversion. Evidence of successful outcomes for:
a Heroin use up to 0.5gm
b Methadone upto 30mg
c Non polydrug users
d Shorter drug and treatment histories
e At an end stage methadone detoxification
Precautions
Severe coronary insufficiency, recent Myocardial Infarction, bradycardia, cerebrovascular
disease, renal failure, pregnancy (teratogenicity and other effects on fetus not known), breast
feeding, cardiovascular problems (evidence of QT prolongation – need for ECG investigation).
Interactions
Lofexidine enhances the effects of CNS depressants including alcohol.
If used along with tricyclic anti-depressants may reduce the efficacy of lofexidine and may
potentiate postural hypotension.
Side effects
Drowsiness, dryness of mucous membranes (dry mouth, throat & nose), hypotension,
bradycardia, rebound hypertension on abrupt withdrawal, sedation and coma in overdosage.
Lofexidine dosing regimes
It could be divided into four phases
ƒ The induction phase: gradually increase the dose to required level, this
reduces the risk of hypotension, allows time for its detection, and to allow time
for its management if it were to occur. In induction phase prescribed opioid
can continue on days 1 and 2.
10
ƒ The peak dosing phase: this is intended to occur during the peak of the opioid
withdrawal symptoms. The length of this phase depends on severity of
withdrawal symptoms.
ƒ The early reduction phase: gradual dose reduction to low dose of two tablets
daily.
ƒ The late reduction phase: one tablet daily for three days to prevent rebound
effects and also assists avoiding a medication gap if starting naltrexone when
required.
The induction and reduction phases are of fixed length depending on severity of opioid
withdrawal symptoms. The peak dosing phase is variable in length and depends on the
expected severity of withdrawal symptoms.
Lofexidine could be used in following clinical situations
ƒ Mild to moderate withdrawal symptoms
o during last days of buprenorphine detoxification treatment
o precipitated
withdrawal during buprenorphine induction from
heroin/methadone
o transfer from low dose methadone(≤30mls) to buprenorphine
o moderate dose methadone(30-60mls) to buprenorphine transfer
o naltrexone induction after low dose buprenorphine stopped
ƒ opioid stabilisation to help stop illicit opioid use on top of methadone or
buprenorphine prescription during titration
ƒ Also, Severe withdrawal symptoms during methadone detoxification from
80mg or less, abrupt buprenorphine withdrawal from moderate or higher doses
or high dose methadone (>55ml) to buprenorphine transfer
11
Phase of
withdrawal
Induction
Mild – Moderate
Opioid
Withdrawal
Severe Opioid
Withdrawal
Both Regimes
Regular Lofexidine
Regular Lofexidine
Prn Lofexidine
Day 1 – 0.2mg qds
Day 1 – 0.2mg qds
0.2mg qds prn daily
Day 2 – 0.4mg tds
Peak dosing
Day 2-5 – 0.2mg qds
Day 3-8 – 0.4mg qds
Early reduction
Day 6 – 0.2mg tds
Day 9 – 0.4mg tds
Day 7 – 0.2 mg bd
Day 10 – 0.2mg qds
Day 11 - 0.2mg bd
Late reduction
Day 8-10 – 0.2mg od
Day 12-14 – 0.2mg od
Total prescribed
tablets
56
112
[0.2mg qds for 14 days] [0.4mg
days]
qds
for
None
14
Practical management points when using Lofexidine:
ƒ withdrawal symptoms should be monitored (either clinically or using rating
scales – SOWS & COWS) and dosing regimen adjusted accordingly.
ƒ During low dose methadone to buprenorphine transfer and during naltrexone
induction, a simplified dosing regimen could be used where peak dosing
(0.2mg qds) is only necessary for 1-2 days.
ƒ If withdrawal symptoms are prolonged or if seen following reduction of
lofexidine, peak dosing could be used for upto 2 more days. But needs caution
as rapid reduction of lofexidine may result in withdrawal like symptoms.
ƒ If opiates were used during lofexidine regimes, peak dosing phase needs
extending by up to 2 days. It is appropriate if client uses once or twice and if
opiate consumption continues then lofexidine regime needs to stopped
gradually and substitute maintenance treatment should be explored.
ƒ Baseline blood pressure both standing & sitting and pulse before commencing
lofexidine and daily monitoring in first few days (upto 4-5 days). If diastolic BP
<50mmhg, then skip the dose. If postural drop in BP >20mmhg, then again
skip the next dose. If service user complaints of dizziness, light headedness,
feeling unwell or tired, skip the dose and needs clinical assessment.
12
ƒ If hypotension or bradycardia is consistent with lofexidine dosing then dose
increase may be delayed or skipped or stop the regime
12
Buprenorphine detoxification
Buprenorphine is opioid partial agonist and indicated for opioid detoxification, substitute
maintenance treatment for opioid dependence and pain management.
Pharmacology
Buprenorphine is a thebaine derivative, has a partial agonistic activity at opioid receptors, has
high affinity for the receptors displacing other opiates. Buprenorphine binds to receptor for
longer period even at low concentrations in blood and may result in prolonged withdrawal
syndrome but less severe in comparison to methadone. Before initiating buprenorphine there
should be evidence of withdrawal due to the risk of precipitated withdrawal and for methadone
its best to leave a gap of up to 36 hours.
Buprenorphine has opiate effect analgesic effect due to partial agonist activity at µ-opioid
receptors. It is administered as sublingual tablet, by intramuscular injection, intravenous
infusion and transdermal patches. It is not administered orally as it has very high first pass
metabolism in hepatic system. Buprenorphine is metabolised by the liver via cytochrome P450
enzyme system into norbuprenorphine and other metabolites. The metabolites are further
conjugated with glucuronic acid and eliminated mainly through excretion into the bile. The
elimination half-life of buprenorphine is 20-73 hours (mean 37hours). As it mainly excreted by
hepatic system it can be used in patients with impaired renal system and in the elderly patients.
Cautions
ƒ
Liver function – high dose buprenorphine can cause changes in liver function in individuals
with history of liver disease. Service users with history of risk factors of liver damage
needs monitoring liver functioning every 6-12 weeks.
ƒ
Intoxication – buprenorphine should be avoided when service users are showing signs of
intoxication (alcohol or other depressant drugs like benzodiazepines). Buprenorphine on
its own is safer but in combination with other sedative drugs can result in respiratory
depression, sedation and coma. These effects may be harder to manage. Very high doses
of naloxone (10-15mg) may be needed to reverse buprenorphine effects (although lower
doses such as 0.8-2mg may be sufficient), hence ventilator support is often required in
cases where buprenorphine is contributing to respiratory depression (e.g., in polydrug
overdose).
13
Contraindications:
Avoid in respiratory depression, acute alcoholism, head injury or raised intracranial pressure,
pheochromocytoma.
Side effects
Nausea, vomiting, constipation, drowsiness, withdrawal symptoms in patients dependent on
opioids, hiccups, dyspnoea, headache, dry mouth, orthostatic hypotension, urinary retention,
decreased libido, ejaculatory dysfunction, hepatic necrosis and hepatitis particularly when
sublingual tablets are crushed and used intravenously.
Regimes
a
Service users using Heroin
After a short induction period of 2-3 days an individual detoxification plan can be
commenced. Following are two examples of regimes that can be followed dependent on
the amount of Heroin used prior to the introduction of Buprenorphine.
Service users using half a gram heroin per day by smoking could commence on 30 days
regime as below. Service users using half a gram by injecting route might need titration up
to 12mg before reduction.
Date
Dose
Mg
Dose
Mg
Dose
Mg
Day
1
4
Date
Day
2
8
14
2.8
26
0.8
3
8
15
2.8
27
0.8
4
8
16
2.8
28
0.8
5
8
17
2
29
0.4
6
6
18
2
30
0.4
7
6
19
2
8
6
20
1.6
9
6
21
1.6
10
4
22
1.6
11
4
23
1.2
12
4
24
1.2
13
4
25
1.2
14
Date
Day
The 2 weeks regime may be used for service users who have reduced their use of Heroin to below a
half-gram per day. Service users using heroin by injecting might need titration of buprenorphine dose
upto 12mg.
Date
b
Day
1
6
2
8
3
6
4
6
5
4
6
4
7
4
8
2
9
2
10
0.8
11
0.8
12
0.4
13
0.4
Dose
Mg
Dose
Mg
Dose
Mg
Date
Day
Date
Day
Service users on Methadone maintenance treatment
Buprenorphine can be introduced following the cessation of Methadone using the following
guidelines.
Methadone
30mls
20mls
10mls
Buprenorphine
6-8mgs
2-4mgs
2-4mgs
Service users who struggle to fully reduce their Methadone can be ‘tailed off’ by the use of
Buprenorphine. Reduction to 10-20mls of Methadone should be achieved as a starting
point and the following regime can be introduced.
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
4mg
4mg
2mg
2mg
0.8mg
0.4mg
0.4mg
This should achieve a rapid detoxification from Methadone over a period of seven days.
15
c
Service users stabilised on Buprenorphine maintenance treatment
A gradual reduction in discussion with service user should be planned to minimise
withdrawal symptoms. Following guidelines may be used:
13
Buprenorphine dose / day
Reduction rate
>16 mg
4mg per week
4 – 16 mg
2-4mg per week
2-4 mg
0.4mg - 2 mg per week
Below 2 mg
0.4 – 0.8mg per week
Methadone detoxification
Methadone detoxification needs to be distinguished from a slow reduction of methadone. In
detoxification program, preparatory work needs to be completed and a momentum of change is
generated so that a drug free state is reached in around 4 weeks time. It may be extended up
to 12 weeks, but efficacy may be reduced.
As methadone has a longer half life, it might be difficult for service users at the final stages of
detoxification. Many service users start using illicit substances to cope with detoxification
program. Hence it is important for good assessment and preparatory work as explained before
and also it is important for service users to engage in psychosocial interventions to develop
alternative coping strategies to address psychological aspects of dependence. Weekly random
drug tests could prove useful to help keep the motivation of service users and also to test for
other drug use. Withdrawal symptoms should be monitored clinically or by using rating scales.
It must be discussed during preparation process about testing arrangements and also that they
can return back to full maintenance treatment if they struggle with the program which could
help psychologically to cope with the anxieties during the program.
At final stages the following ways could be tried –
ƒ continue with methadone detoxification with service users agreement
ƒ discussion with service users about switching to buprenorphine and then to
continue with detoxification program
ƒ discussion about lofexidine program
16
ƒ discussion about symptomatic relief program on its own or as an aid to
continue with methadone detoxification program
ƒ discussion of available option of returning to maintenance treatment if they
relapse
Detoxification program should be planned on case by case basis in consultation with service
user. Following the detoxification program, Naltrexone can be prescribed after 10 days interval
but even may precipitate withdrawal symptoms. It may be useful to use naloxone challenge
test.
Pharmacology
Methadone is a synthetic opioid, although chemically unlike to morphine or heroin it acts on
opioid receptors and thus has same effects. Methadone maintenance treatment for opioid
dependence is extensively and systematically studied. It is also used in management of chronic
pain due to it long duration of action.
Methadone is a full mu-opioid agonist for its opioid effects; also it binds to the glutamate NMDA
receptor resulting in antagonist activity against glutamate and this may be one mechanism by
which it decreases craving for opioids. Methadone has a slow metabolism and very high fat
solubility resulting in long duration of action. The elimination half life is 15 to 60hours with a
mean around 22-24hours. Metabolism rates vary greatly between individuals due to genetic
variability in the production of metabolic enzymes CYP3A4 and CYP2D6. A longer half life
usually allows for once daily administration in opiate detoxification and maintenance
treatments. Patients with rapid metabolisation may require twice daily dosing to obtain
sufficient symptom alleviation while avoiding excessive peaks and troughs in their blood
concentrations allowing for lower total doses in some such patients. The analgesic effect is
shorter than the pharmacological half-life, dosing for pain control usually requires multiple
doses per day. The most common route of administration is oral solution. It is also
administered in oral tablets, subcutaneous, intravenous and intramuscular ampoules.
Cautions
Cardiovascular risk factors, prolonged QTc interval, Hypotension, hypothyroidism, asthma
(avoid during an attack), decreased respiratory reserve, prostatic hypertrophy, hepatic and
renal impairment, elderly, convulsive disorders.
Contraindications
Avoid in acute respiratory depression, acute alcoholism, excess benzodiazepine use, head
injury or raised intracranial pressure, where risk of paralytic ileus, phaeochromocytoma.
17
Side effects
Nausea, vomiting, constipation (decreased bowel motility), hypoventilation, miotic pupils,
drowsiness, hypotension, muscle rigidity, difficulty in micutuirition, dry mouth, sweating,
headache, facial flushing, vertigo, bradycardia, tachycardia, palpitaions, postural hypotension,
hypothermia, mood changes, decreased libido, rashes, pruritus and urticaria.
Sample methadone detoxification programs with different periods.
Detoxification from 55mls
of methadone
Detoxification from 30mls
of methadone
Detoxification from 30mls
of methadone
Day 1
50mls
26mls
26mls
Day 2
50mls
24mls
24mls
Day 3
45mls
24mls
18mls
Day 4
45mls
22mls
14mls
Day 5
40mls
22mls
12mls
Day 6
40mls
22mls
10mls
Day 7
40mls
18mls
8mls
Day 8
35mls
18mls
6mls
Day 9
35mls
18mls
4mls
Day 10
30mls
16mls
2mls
Day 11
30mls
16mls
Day 12
26mls
12mls
Day 13
26mls
12mls
Day 14
22mls
10mls
Day 15
22mls
10mls
Day 16
18mls
8mls
Day 17
18mls
8mls
Day 18
14mls
6mls
Day 19
14mls
6mls
Day 20
10mls
4mls
Day 21
10mls
4mls
Day 22
6mls
4mls
Day 23
6mls
2mls
Day 24
4mls
2mls
Day 25
4mls
Day 26
2mls
Day 27
2mls
Day 28
2mls
18
14
Relapse Prevention and Aftercare following detoxification
Maintenance of abstinence and relapse prevention is a key stage in the journey of addiction for
a successful outcome and meaningful change in the service user’s life. As a routine treatment,
support and monitoring should continue to facilitate maintenance of abstinence and this should
be for a period of at least 6 months. Please refer to Turning Point document about the services
and support available for service users during and following the detox programme.
Naltrexone
Naltrexone is an opioid antagonist indicated for prevention of relapse in opioid misusers.
Evidence suggests that combination treatment of Naltrexone and psychosocial interventions is
more effective than either treatment alone. Available published evidence inidicates that a
minority of service users wish for naltrexone treatment, naltrexone treatment program has a
very high drop out rate and service users continuing treatment for 3 months or more are more
likely to remain abstinent. As activation of opioid receptors produces sense of well being,
Naltrexone blockade of these receptors may produce dysphoria, which might contribute
towards non compliance and drop out from treatment. Naltrexone assessment should be
undertaken to determine service users suitability for the treatment because of the risk issues as
detailed below.
Also more evidence is emerging about use of naltrexone in alcohol dependence to help with
physiological craving for the substance and hence being used in north American countries and
also in some centres in UK. But in UK Naltrexone is not licensed for use in alcohol
dependence.
Pharmacology:
Naltrexone can be described as a substituted Oxymorphone (Oxymorphone is a semi-synthetic
opioid analgesic and is 6-8 times more potent than morphine). Naltrexone is rapidly absorbed,
with peak blood levels achieved about 1 hour after oral administration. Naltrexone is
metabolised mainly to 6β-naltrexol by the liver enzyme dihydrodiol dehydrogenase. Other
metabolites include 2-hydroxy-3-methoxy-6β-naltrexol and 2-hydroxy-3-methoxy-naltrexone.
These are then further metabolised by conjugation with glucuronide and excreted by renal
system. Naltrexone has a relatively short plasma half-life of 4 hours and its metabolite 6βnaltrexol has a half life of about 10 hours.
Naltrexone has a high affinity for opioid receptor sites. Naltrexone, and its active metabolite 6βnaltrexol, are competitive antagonists at µ- and κ-opioid receptors, and to a lesser extent at δopioid receptors. They therefore competitively displaces opioid agonists if they are present, but
has little intrinsic action of their own. Opioid antagonistic action could last upto 72 hours.
19
Naltrexone is marketed as its hydrochloride salt, Nalorex, scored yellow tablet containing a
dose of 50mg.
Contraindications:
Currently physiologically dependent of opioids and they would need to undertake detoxification
program; acute hepatitis or liver failure; if service users are using opioids for physical condition;
currently suffering with withdrawal symptoms and would need wash-out period of 7-10 days; if
they have previous history of allergy/sensitivity to naltrexone.
Cautions:
Hepatic or renal impairment; liver function tests before and during treatment; pregnancy and
breast feeding; poly-substance dependence; major physical or mental health problems.
Side effects:
Nausea, vomiting, abdominal pain; anxiety, sleeping difficulty, headache, low energy; joint &
muscle pain; feeling down, loss of appetite, irritability, delayed ejaculation.
ƒ Service users should be made of aware of above side effects and that they
tend to be transient, mild and should get better with the course of treatment.
Although major adverse effects have not been reported directly related to naltrexone, again
service users should be strongly advised about the risk of opioid over dose and death if they
were to relapse to opioid use. Service users should be made aware that any dose of heroin
which they used to use before may prove fatal. And also the risk of service users using more
opioids to overcome the blockade effect of naltrexone to achieve the euphoric relaxed state.
Practical issues:
Naltrexone should be used along with psychosocial interventions to help the client prevent a
relapse back to opioid use following detoxification. Service users should be given all the
information about the treatment and that any use of heroin or other opioid drugs will have no
effect. Hence Naltrexone could be viewed as a treatment helping the service user to address
the issues of craving and sudden temptation to use opioids. Psychosocial interventions should
be aimed to help service users to develop psychological coping strategies to stop them wanting
to use heroin and maintain their motivation to remain abstinent. The Cochrane review
concluded that certain circumstances may increase the probability of a positive outcome of
naltrexone treatment such as stable social contacts, occupation, a confidential relationship with
the therapist and clear instructions about the treatment, with participants informed consent.
20
Service users should be made aware and cautioned of the risks of adverse events such as
fatal overdose in those who relapse to opioid use. Also service users should be warned of the
risk of acute opioid toxicity if any attempt to overcome the blockade effect of naltrexone.
Naltrexone has the potential to precipitate severe withdrawal symptoms in those who are
currently using or were previously taking opioid drugs and where enough wash-out period not
given.
A thorough assessment should be undertaken with regards to their opioid use and also if they
have used any opioid-containing preparation unknowingly (ex., over the counter analgesics).
The minimum wash-out period required depends on the type of opioid use, duration of use and
amount taken as a last dose. Opioids with long half lives like Methadone may require wash-out
period of up to 10 days and with shorter half lives such as heroin may require up to 7 days.
With Buprenorphine wash-out period of 7 days is sufficient if final dose was >2mg and duration
of use was >2 weeks, and naltrexone may be started in 2-3 days if final dose was <2mg and
duration of use was <2 weeks.
A test dose of naloxone (0.2mg) with much shorter half life than naltrexone, may be
administered as a precautionary measure as precipitated withdrawal symptoms are of much
shorter duration in comparison to naltrexone.
Every effort should be made to involve the carer or family member to support the service user
during the treatment program which is significant for a successful outcome. Evidence shows
that at the onset of treatment during first 5-7 days, supervision of Naltrexone medication by a
family member or carer is associated with improved outcomes. Supervision of medication could
be discussed and agreed before commencement of the program. Care plan should be
discussed with the service user and/or carer, family members or friends where supervision of
medication, a record of medication taken, its effect and service user’s mood state throughout
the program needs to be agreed before commencement of treatment.
Investigations necessary before entering naltrexone treatment program:
ƒ Liver function tests should be completed before starting the treatment and it
is recommended that tests are repeated every week for 6 weeks and at
regular intervals of around 1 month. If test results are abnormal should be
used cautiously and naltrexone is used in alcohol dependence with rare
adverse outcomes. Hence the need for regular monitoring and tests.
21
Guidance to follow would be –
ƒ stop using if liver functions tests reveal raise in Alanine Transaminase
enzyme
(serum
glutamate
pyruvate
transaminase
or
alanine
aminotransferase) levels more than twice the normal range.
ƒ Therapeutic window - the toxic dose is around 5 times that of normal
therapeutic dose. Needs good titration of dose and monitoring.
ƒ Pregnancy test
ƒ Urinalysis or oral mucosal fluid sampling to ensure opioid free state allowing
for wash-out period time for relevant opioids, naloxone challenge test could be
useful.
Please refer to Appendix 3 for Naltrexone assessment details, assessment form and
pathways for service users in community, local prison and non-local prisons.
The naltrexone treatment program can be commenced as follows:
Breakfast
Lunch
Day 1
12.5mg
Supper
Bedtime
(¼ tab)
Day 2
Day 3
12.5mg
12.5mg
(¼ tab)
(¼ tab)
25mg
(½ tab)
Day 4
50mg
Continue the prescription Naltrexone 50mg on a daily basis.
Service user should be advised to stop taking if there is any reaction.
16
Naloxone challenge test
Aims to confirm physiological dependence state on opioids. Nalxone has much shorter half life
and any withdrawal symptoms precipitated will be of shorter duration than if precipitated by
naltrexone.
22
A test dose of Naloxone 200 microgram I. V. or I.M. is administered and observed for opioid
withdrawal symptoms. After 30 min, if no withdrawal symptoms are precipitated give naloxone
600 microgram I.M. (1.5ml) and continue observing for withdrawal symptoms
If withdrawal symptoms are precipitated Naltrexone treatment should not be initiated and
Naloxone challenge test to be repeated 3 days later.
Pharmacology of Naloxone:
Naloxone is an opioid antagonist and is specifically used to reverse the life-threatening
depression of central nervous system and respiratory system.
Naloxone should not be confused with naltrexone which is used for relapse prevention in
dependence treatment rather than for emergency overdose situation.
Naloxone has very high affinity for µ-opioid receptors in central nervous system and low affinity
at κ- and δ-opioid receptors. It is synthesised from thebaine also called paramorphine, an
opiate alkaloid, constituent of opium. Chemical structure of naloxone resembles that of
oxymorphone except that an N-methyl group is substituted with an allyl group. The naloxone
derives from N-allyl and oxymorphone. It has fast onset of action and short duration of action,
if used IV action starts with in 2 minutes and its effects could last up to 45 minutes. Naloxone
has no bioavailability when used orally unlike naltrexone.
Naloxone is available in injection ampoules, 400micrograms/ml and can be used intravenously,
subcutaneous and intramuscularly.
Indications:
Reversal of opioid induced respiratory depression, reversal of neonatal respiratory depression
resulting from opioid administration in mothers, overdosage with opioids.
Cautions:
Cardiovascular disease, physiological dependence on opioids
Side effects:
Hypotension, hypertension, ventricular tachycardia and fibrillation, cardiac arrest,
hyperventilation, dyspnoea, pulmonary oedema and less commonly agitation, excitement,
paraesthesia.
23
17
APPENDIX 1: Clinical Opiate Withdrawal Scale
Date: .......................
Name: ................................................
FI No: .......................
For each item, circle the number that best describes the client’s signs or symptoms. Rate on just the
apparent relationship to opiate withdrawal. For example, if heart rate is increased because the client
was jogging just prior to assessment, the increased pulse rate would not add to the score.
Score
Score
Resting Pulse Rate:
GI Upset: over last ½ hour
______ beats/minute
0 no GI symptoms
Measured after client is sitting or lying
for one minute.
1 stomach cramps
2 nausea or loose stool
0 pulse rate 80 or below
3 vomiting or diarrhoea
1 pulse rate 81-100
5 multiple episodes of diarrhoea
or vomiting
2 pulse rate 101-120
4 pulse rate greater than 120
Sweating: over past ½ hour not
accounted for by room temperature or
client activity.
Tremor:
observation
outstretched hands
of
0 no tremor
0 no report of chills or flushing
1 tremor can be felt, but not
observed
1 subjective report of chills or flushing
2 flushed or observable moistness on
face
2 slight tremor observable
4 gross tremor or muscle twitching
3 beads of sweat on brow or face
4 sweat streaming off face
Restlessness:
assessment
Observation
during
Yawning: Observation
assessment
during
0 able to sit still
0 no yawning
1 reports difficulty sitting still, but is able
to do so
1 yawning once or twice during
assessment
3 frequent shifting or
movements of legs/arms
2 yawning three or more times
during assessment
extraneous
5 unable to sit still for more than a few
seconds
4 yawning several times/minute
Pupil size:
Anxiety or Irritability:
0 pupils pinned or normal size for room
light
0 none
1 client reports increasing
irritability or anxiousness
1 pupils possibly larger than normal for
room light
2 pupils moderately dilated
2 client obviously irritable or
anxious
5 pupils so dilated that only the rim of
the iris is visible
4 client so irritable or anxious that
participation in the assessment is
24
difficult
Bone or Joint Aches: If client was
having pain previously, only the
additional component attributed to opiate
withdrawal is scored
Gooseflesh Skin:
0 skin is smooth
3 pilo-erection of skin can be felt or
hairs standing up on arms
0 not present
5 prominent pilo-erection
1 mild diffuse discomfort
2 client reports severe diffuse aching of
joints/muscles
4 client is rubbing joints or muscles and
is unable to sit still because of
discomfort
Total Score: __________
Runny Nose or Tearing: Not
accounted for by cold symptoms or
allergies
The total score is the sum of all
11 items
0 not present
1 nasal stuffiness or unusually moist
eyes
Initials of person completing
assessment: __________
2 nose running or tearing
4 nose constantly running or tears
streaming down cheeks
Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal.
25
18
APPENDIX 2: Short Opiate Withdrawal Scale
NAME
DATE
TIME
Please tick the appropriate box if you have suffered from any of the following
symptoms in the last 24 hours
NONE
MILD
MODERATE
Feeling sick
Stomach cramps
Muscle spasms or
twitching
Feelings of coldness
Heart pounding
Muscular tension
Aches and pains
Yawning
Runny eyes
Insomnia or problems
sleeping
TOTAL
26
SEVERE
19
APPENDIX 3
Naltrexone assisted relapse prevention should only be initiated by specialists and specialist
experienced generalists in this technique
There needs to be an understanding of the crucial role of psychological interventions in
achieving and maintaining abstinence.
Where it is set up, shared care arrangements should be clearly delineated, between the
specialist and the patient’s general practitioner.
We would suggest the following approaches:
1
Client within community team:
1.1 The relevant drug worker/care coordinator will undertake a comprehensive assessment, or
a detailed additional assessment where a Comprehensive assessment already exists,
focussing specifically on the areas detailed in section 1.1 above (SMS Naltrexone
Assessment Form)
1.2 The case will be reviewed with the relevant clinical lead for the team prior to being
presented at the local CDT meeting in the normal way.
1.3 Where an agreement to naltrexone prescribing is indicated at the CDT meeting, an early
appointment will be arranged with consultant and the case put forward for review of
prescribing in the normal way, with Care Plan and comprehensive treatment package
outlined.
1.4 The case will be reviewed with the medic at no less than 3 monthly intervals, and sooner if
indicated. Liver function tests need to be undertaken, and the frequency of these will
depend on past history of liver problems, obesity, alcohol use, older adults and at the
request of the medical practitioner (prescribing guide lines state liver function tests should
be carried out prior to, and throughout the treatment period) these results may be required
at the formal reviews.
1.5 Given the risks associated with naltrexone, particularly in relation to very minimal tolerance
to heroin and opiate based drugs, any suggestion of use of such drugs on top of the
prescription must receive urgent attention and referral to consultant. This will require
random swab testing throughout the treatment period
27
1.6 Normal period of naltrexone prescribing would not exceed 12 months, and more routinely
work would be undertaken with the aim, given an appropriately targeted client, of
supporting withdrawal between 3 and 6 months.
1.7 Where the client is appropriately targeted and circumstances indicate a settled and stable
situation, it is not anticipated that oversight of naltrexone prescribing need remain with the
Consultant beyond the first consultation, unless that is the Consultant identifies factors in
the case that would require the case to remain with them.
1.8 It is anticipated that naltrexone prescribing will be suitable for a relatively small number of
closely targeted and assessed clients
2
Client being released from custody:
2.1 Where the client is in a local prison the DIP In-Reach worker will undertake a full
comprehensive assessment, and will specifically focus on the following areas:
ƒ Previous treatment interventions and response i.e. what, when and success or
otherwise. Clearly where a client’s circumstances do not indicate previous
consistent engagement with treatment agencies towards establishing a stable
and managed position regarding their drug use, and preferably some
indication of previous attempts to withdraw from opiates, then it may be
reasonable to take the view that naltrexone might not be the best option.
Exceptions to this may include a long prison sentence where the client has
clearly engaged consistently with treatment and support agencies in the prison
and in the community, and has developed a clear perspective on naltrexone
prescribing as part of a detailed treatment package upon release.
ƒ Liver Function Test (LFTs) clearly indicate the suitability of the client
ƒ Accommodation – must be stable and settled accommodation, with no other
drug users indicated as present at the accommodation
ƒ Social support networks – range of support that will reinforce a drug free
lifestyle
ƒ Lifestyle and associates – no indication of close and primary contact with a
drug using group of friends/family
ƒ Prepared to engage with Harm Reduction and Relapse Prevention work as
part of a comprehensive treatment package
28
ƒ Employment/training opportunities either identified or prepared to explore as
part of comprehensive treatment package
If all these criteria can be met then the individual would be suitable for Naltrexone
prescribing, under supervised conditions.
2.2 Where the client is not located in a local prison then the DIP Throughcare and Aftercare
Care Coordinator will work with the CARAT and Healthcare staff within the relevant prison
to ensure that a triage assessment, incorporating the key areas for assessment as noted
above, is completed and a copy faxed to the care coordinator.
2.3 Having received the relevant information and reviewed any history of contact with
treatment services that may be available, the DIP worker will review the referral for
naltrexone prescribing with the clinical lead for DIP. Where the assessment indicates that
all or most of the assessment criteria are met, referral for naltrexone prescribing will
progress, as usual, via the CDT team meeting in the relevant area.
This will include
identification of drug worker, where DIP worker is unable to hold clinical responsibility for
the case at that time, but where the DIP worker would continue to act as care coordinator
in relation to the Care Plan. Transition to shared care should be instigated within a two
week period.
2.4 Where an agreement in principle to naltrexone prescribing is indicated at the CDT
meeting, the assessment and details of the case will be presented to the Consultant, in
paper form, and an agreement to support naltrexone prescribing confirmed.
2.5 The prison will be informed of the decision as to whether Worcestershire CDT are able to
support the prescribing of naltrexone on release
a
Where naltrexone can be prescribed on release – (see prescribing guidelines
Department of Health) the prison will be informed in writing and this will involve them
undertaking all the necessary clinical tests prior to commencing naltrexone
prescribing before release. The prison would normally release with up to 7 days
supply of naltrexone. An early appointment with the Consultant will be arranged
within seven days post release, when the continuation script will be confirmed and
Care Plan including comprehensive treatment package to support naltrexone
prescribing regime confirmed.
b
Where naltrexone cannot be prescribed on release. – the prison will be informed
in writing with reasons as to why the client does not meet the local assessment
criteria, or if for clinical reasons the use of naltrexone is contra indicated. CARAT
and healthcare staff will be asked to explore alternative treatment options with the
29
client prior to release. An early appointment with DIP throughcare and aftercare
worker will be confirmed upon release and a detailed review of alternatives and a
Care Plan completed. This may include working with partnership agencies with
regards to relapse prevention.
2.6 Where naltrexone prescribing is indicated – case will be reviewed with the medic. Liver
function tests need to be undertaken, and the frequency of these will depend on past
history of liver problems, obesity, alcohol use, older adults and at the request of the
medical practitioner (prescribing guide lines state liver function tests should be carried out
prior to, and throughout the treatment period) these results may be required at the formal
reviews.
2.7 Normal period of naltrexone prescribing would not exceed 12 months, and more routinely
work would be undertaken with the aim, given an appropriately targeted individual in the
first place, of supporting withdrawal between 3 and 6 months
30
Worcestershire Mental Health Partnership NHS Trust
Substance Misuse Service
Assessment Form for the use of Naltrexone
Name
Home Address
Prison and Prison No.
Pregnant
YES
NO
History of previous
Treatment
Interventions
Successful or otherwise.
Has there been previous
consistent engagement.
Have there
attempts to
opiates.
been previous
withdraw from
Compliance to treatment
Accommodation
Are drug users indicated as
resident at this address, is it a
settled stable environment
Liver Function Test Results
Social Support Networks
What support is there to reinforce
a drug free lifestyle?
Prepared to engage with
harm reduction and relapse
prevention work
31
Employment/Training
Opportunities
Please complete tick boxes if client fulfils the criteria in all area Yes
then in principal they would be a suitable candidate for prescribing
History of previous treatment
Accommodation
Liver Function Test
Social Support
Lifestyle and associates
Prepared to engage in Harm Reduction/Relapse prevention
Employment/Training opportunities
Name and Signature
Of assessor
Assessment Date
Further Action
Required
32
No
Proposed Care Pathway Prescribing Naltrexone within the community teams
Worker will
undertake a SMS
Naltrexone
Assessment Form
Discuss with
relevant clinical lead
for the team an
present at clinical
meeting
If suitable
If not suitable
Discuss further
treatment options
with the client and
signpost to the
appropriate services
Appointment made
with prescribing
specialist
(Consultant)
Consultant Confirms
Prescription
Shared care
arrangements
should be delineated
33
Proposed Care Pathway Prescribing Naltrexone
From Local Prisons
Access for clients in
local prisons
Full assessment by
DIP prison in reach
Worker
Discuss with DIP
clinical lead
If suitable
If not suitable
Communication with
Prisons and Sign
post through DIPs
for appropriate
treatment plans
Discussed in clinical
team meeting
Appointment made
with prescribing
specialist
(Consultant)
Local Treatment
Agencies
Consultant Confirms
Prescription
Information sent to
prison to confirm
prescribing
Shared care
arrangements
should be delineated
34
Propose Care Pathway Prescribing Naltrexone
Not in Local Prison
Communication with
DIPs staff, Health
Care and CARATs
ensuring full
assessment
incorporating key
areas.
Refer back to prison
for Retox scripting in
preparation for
release
Discuss with DIP
Clinical Lead
If suitable
If not suitable
Discussed in clinical
team meeting
Appointment made
with prescribing
specialist
Local treatment
agencies
Consultant Confirms
Prescription
Shared care
arrangements
should be delineated
Communicate with
Prison Sign post
through DIPs for
appropriate
treatment plans on
release
Information sent to
prison to confirm
prescribing
35
20
Appendix 4
The following is aimed at helping the service user and keyworker/care co-ordinator to draw a
comprehensive care plan during the preparatory process for detoxification program and for after care:
Service User Name:
Keyworker:
Date:
1.
Identify and please list high risk situations/triggers for craving which could lead to relapse into
drug taking behaviour following the completion of detoxification program?
2.
Please list the strategies you have considered and developed to avoid or limit exposure to high
risk situations?
3.
List below the skills you have considered and developed to manage cravings and other painful
emotions without using drugs?
4.
Print below the relapse prevention plan to cope with lapses into drug taking behaviour?
36
5.
What is your action plan to recognise, challenge and manage unhelpful or dysfunctional
thoughts about drug misuse?
6.
What is your emergency plan for coping with high-risk situations when other skills are not
working?
7.
What is your action plan to recognise how you might ‘set yourself up’ to use illicit drugs?
8.
Please list the skills you have developed and engaged in generating pleasurable sober
activities and relationships, improving quality of life and attaining a lifestyle balance?
37
21
Flow chart
Service user expresses the wish for opioid detoxification
Case discussed at Referral / team meeting in presence of Turning Point staff
Clinic appointment booked in 1-2 weeks time
If considered suitable, preparation work to draw up a clear care plan
Assessments completed from Community Rehab and or Turning Point
Care Co-ordinator to liaise care between different agencies
Clinic appointment booked and detox program decided
In-patient detox
community detox
Assessment for Naltrexone treatment program
After care to maintain abstinence and relapse prevention
Joint working between Care Co-ordinator, CDT staff (Naltrexone treatment),
Community Rehab, Turning Point for a period of at least 6 months
38
23
Useful References
1
Seifert J, Metzner C, Paetzold w et al. detoxification of opiate addicts with multiple drug
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2
JHarding-Pink d. Methadone: one person’s maintenance dose is another’s poison. Lancet
1993; 341: 665-666.
3
Lingford-Hughes AR, Welch S, Nutt AJ. Evidence based guidelines for the
pharmacological management of substance misuse, addiction and comorbidity:
recommendations
from
the
British
Association
for
Psychopharmacology.
J
Psychopharmacology 2004; 18: 293-335.
4
Prescribing guidelines. 8th edition. The south London and Maudsley, Oxleasturst.
5
NTA guidelines. Drug Misuse and Dependence – UK Guidelines on Clinical Management
2007.
http://www.nta.nhs.uk/areas/clinical_guidance/clinical_guidelines/docs/clinical_guidelines_
2007.pdf
6
NICE guidelines. Drug misuse: opioid detoxification. http://guidance.nice.org.uk/CG52
7
NICE guidelines. Drug misuse – naltrexone. http://guidance.nice.org.uk/TA115
8
NICE
guidelines.
Drug
misuse:
psychosocial
interventions.
http://guidance.nice.org.uk/CG51
9
Eissenberg TR, Johnson RE, Bigelow GE et al. Controlled opioid withdrawal evaluation
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10 Community prescribing guidelines for substance misuse service. Birmingham and Solihull
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11 Schmittner J, Schroeder JR, Epstein DH et al. QT interval increased after single dose of
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12 Kirchmayer U, Davoli M, Verster A. Naltrexone maintenance treatment for opioid
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13 Tucker T, Ritter A. Naltrexone in the treatment of heroin dependence; a comprehensive
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39
14 Guidelines for substance misuse. Sandwell mental health trust.
15 Gossop M, Marsden J, Stewart D, Treacy S. Outcomes after methadone maintenance and
methadone reduction treatments: two-year follow-up results from the National Treatment
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16 Green L, Gossop M. Effects of information on the opiate withdrawal syndrome. British
Journal of Addiction 1988;83:305-309.
17 Bell J, Kimber J, Lintzeris N, White J, Monheit B, Henry-Edwards S, et al. Clinical
Guidelines and Procedures for the Use of Naltrexone in the Management of Opioid
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18 Cochrane Reviews. Alpha2 adrenergic agonists for the management of opioid withdrawal.
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40