Integrated treatment of opioid dependence

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Integrated treatment of opioid dependence

• Robertas Badaras
• Vilnius Toxicology Clinic
• 2004

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Key concepts in dependence I

• Drug abuse self administration of a drug that
  deviates from approved medical or social
  standards, and that has adverse consequences for
  individual
• Addiction compulsive drug use associated with
  strong craving and preoccupation with obtaining
  and using the drug for its rewarding effects

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Key concepts in dependence II

• Tolerance decreased efficacy of a drug
  associated with long term administration
• Physical dependence altered physiological state
  produced by long term administration in which
  target tissues adapt and require drug for normal
  functioning
• Discontinuation produces withdrawal or abstinence

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The acute opioid withdrawal syndrome

• Strong Flu-like symptoms
• Gooseflesh (going cold turkey)
• Muscle tremor and twitches (kicking the habit)
• Abdominal cramps and diarrhea
• Increased heart rate, blood pressure
• Hyperventilation

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Opioid dependence patients choices

• No problem at all or something must be changed?
• Now or later?
• Treatment or harm reduction?
• By my own or by specialists?
• In-patient or out-patient settings?
• Which detoxification technique?
• Which way after detoxification?

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Opioid dependence specialists choices
Opioid dependence
Integrated treatment
Detoxification
Long-term (lifelong?) substitution
Naltrexone
Supportive treatment
Rehabilitation
?
Results
Harm reduction
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Patients evaluation I

• History
• Motivations and goals for treatment
• Opioid use quantity and frequency
• Other drugs
• High-risk drug behaviours, particulary overdoses,
  self-injury
• Prior attempts for withdrawal, maintenance and
  other treatment
• Social circumstances

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Patients evaluation II

• Examination
• Vital signs
• Pregnancy or lactation
• Evidence of intoxication or withdrawal from
  opoids or other drugs
• Evidence of complications of drug use
• Urinary drug screens
• Liver function test and viral serology

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Detoxification techniques

• Without any medical support (dry detox)
• Traditional
• Substitution with reducing doses of opioids
• Rapid opioid detoxification
• under general anesthesia (Ultra Rapid Opioid
  Detoxification)
• under sedation (Rapid Opioid Detoxification)

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Dry detox

• Painful and discomfortable
• High level of risk
• Very high level of drop out

Its a punishment, not a treatment
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Traditional detoxification

• Medicine
• no opioids
• BZD, clonidine, carbamazepine q.s.
• infusion therapy
• Disadvantages
• long duration (7 up to 28 days)
• large amount of relapses
• high costs and low effectiveness

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Substitution with reducing doses of opioids

• Drug of choise is buprenorphine partial agonist
  at the ? receptors and ? (kapa) antagonist
• Doses should be titrated against severity of
  withdrawal
• Usual duration 7 -10 days

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Substitution with reducing doses of opioids

• Advantages
• outpatients regime
• safety
• low costs
• Disadvantages
• large amount of relapses
• Impossibility to stop using

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Ultra Rapid Opioid Detoxification I

• An acute abstinence induced by opiate antagonists
  under the general anaesthesia or deep sedation
• Performed only in ICU (ALV) with skilled staff
• Duration of procedure 4-12 hours
• Induction of abstinence
• Naloxone/Naltrexone (full dose 1-4 hours after
  heroin intake)
• Correction of withdrawal symptoms
• alfa2 agonists (clonidine)
• octreotid
• symptomatic treatment

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Ultra Rapid Opioid Detoxification II

• Advantages
• early opioid antagonist induction
• real possibility to elevate all withdrawal
  symptoms
• Disadvantages
• very high costs
• 6 reported cases of death worlswide during the
  procedure
• complications of ALV and general anaesthesia

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Rapid Opioid Detoxification

• Opioid abstinence precipitated by administration
  of naltrexone and/or naloxone on in-patient
  settings
• Correction of symptoms of withdrawal
• Duration of detoxification 2-3 days
• Naltrexone doses of 0,2-10 mg prior to full dose
  (optional)
• Naltrexone full 50 mg dose 24-36 hours after
  heroin intake

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Rapid Opioid Detoxification

• Indications
• seeking for full abstinence, independent of
  duration, quantity, frequency and technique of
  opioids using
• evidence of complete physical and psychological
  opioid dependence
• agreement for this detox technique

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Rapid Opioid Detoxification

• Relative contraindications
• mental disorders, which can limit the
  collaboration
• planning treatment with opioid agonists

Multisubstance abuse isnt contraindication for
ROD
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Rapid Opioid Detoxification

• Absolute contraindications
• disagreement for this detox technique
• severe somatic diseases sepsis, cardiovascular
  insufficiency
• pregnancy
• acute psychosis
• consciousness impairment (GCS lt15)
• recently surgical intervention

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Rapid Opioid Detoxification

• Standart medications for symptomatic treatment
• infusion therapy up to 3000 ml crystaloids per
  day
• alfa2 agonist clonidine (0,6-1,2 mg per day)
• TIA - doxepin up to 50100 mg per day
• BZD - diazepam up to 100 mg per day
• Neuroleptics - droperidol up to 5 mg per day
• octreotid (0,1-0,2 mg per day)
• MgSO4, NSAID

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Rapid Opioid Detoxification

• Advantages
• short duration
• early opioid antagonist induction,
  irreversibility of procedure
• real possibility to elevate withdrawal symptoms
• low costs
• Disadvantages
• risk of psychosis, seizures, aspiration
• bradycardia, hypotension according to clonidine
  usage

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Postdetoxification period

• Pharmacological correction
• sleep disturbances
• depression
• treatment of acquired collateral diseases
• Psychotherapy
• group therapy
• personal therapy
• Social rehabilitation
• Long-term naltrexone therapy

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Naltrexone

• Marketed from 1984
• Molecular structure is close to naloxone
• Opioid Capa and Delta receptor antagonist
• Inhibits perception of opioid induced euphoria
• Has no effect on craving
• No abuse potential
• Most suitable for long-term opioid antagonist
  therapy
• Hepatotoxic effects are possible only after huge
  doses

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Naltrexone (administration)

• Without rapid detox techniques
• 5-7 days after heroin intake
• 10-14 days after methadone intake
• Problem early introduction of naltrexone (i.e.
  up to 5 days after heroin and 10 days after
  methadone intake) without special measures may
  produce severe withdrawal. Delirium, seizures,
  severe cardiovascular and gastrointestinal
  symptoms are possible
• 1 time per day
• Recommended duration of therapy 0,5-3 years
• Side effects dysphoria, abdominal pain, loss of
  concentration, co-ordination impairment are
  rare

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Reasons of relapse
Motivation
Detoxification
Severe withdrawal Lack of motivation Long
duration of detox
Craving Repeated usage resulting in euphoria and
withdrawal Psychological and social reasons
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Prevention of relapse
Detoxification
Motivation
Rapid detox methods
Naltrexone Supportive medical treatment Psychother
apy Social rehabilitation
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Conclusions

• Integrated complex treatment scheme with
  naltrexone could be a golden standard in
  treatment of opioid abuse
• Effectiveness of opioid detoxification is
  directly related to correct evaluation and
  selection of patients
• Rapid detoxification methods allows early
  introduction of naltrexone, thus decreasing
  incidence of early relapses