Drug Detoxification revisited

1
Drug Detoxification revisited

• Dr Lucy Cockayne
• Consultant Psychiatrist
• NHS Lanarkshire

2
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?

3
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.

4
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.
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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

6
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.

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Opiate detox the options

• Broadly three types of detox
• Tapering eg methadone reduction
• Transitional/substitution eg subutex/lofexidine
• Rapid opiate withdrawal using naltrexone

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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

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From UROD to NIMROD

• Various methods varying from
• Using anaesthesia (UROD)
• Takes as little as 4 hours
• Risks of anaesthesia (some deaths)
• Asturian technique
• 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

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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
Blocks only Can be used to maintain abstinence No
potential for respiratory depression
m receptors
No neurotransmission
No effect
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Subutex vs lofexidineWhite R et al. Drug Alcohol
Depend 2001 65 77-83

• Subutex
• Higher completion rate
• Less severe withdrawal syndrome

100
n 69 P 0.04
Two thirds
80
One third
60
patients completing detoxification
40
20
0
Subutex
lofexidine
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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?

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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).

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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

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Improving compliance

• Entrusting administration to a relative or carer
  (Anton, 1981)
• Contingency contracting (Preston, 1999)
• Naltrexone administered by probation officers
  (Cornish, 1997)

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Chan and Cornish Papers

• Chan 1996 Singapore
• Highly structure jail release programme
• NTX 3x weekly 100100150
• 75 compliance at 12 months on NTX
• 25 not on NTX
• Cornish et al 1997 USA
• twice weekly doses - M100F150
• NTX halved re-offending

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Implants- new boy on the block

• slow release naltrexone implants
• 6 week (Wedgewood Marlburg)
• 3 - 12 month (ONeil)
• device NOT licensed for humans
• No prospect of USA licence.
• ONeil licence procedure ongoing

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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

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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

20
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)

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UK Evidence Stapleford study

• 150 consecutive patients
• 6 week naltrexone implants - two year period,
• opiate-free- 100 at 5 weeks
• 80 at 3 months
• 60 at 6 months
• Re-implantation- 41 second implant
• 18 third implant
• 13 fourth implant
• 5 fifth implant
• (Brewer, 1999).

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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

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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.