How good is opioid treatment?
Treatments for addiction problems have much in common regardless of the substance. It is often assumed that all heroin or opioid users want a substitute prescription - as with any other drug some people are ready to stop using now and get on with a detoxification. Practitioners need to be ambitious for heroin and other opiate users and be positive about the goal of becoming drug-free. It is easy just to keep taking a substitute medication but few regret getting drug free.
① Stabilisation ② Relapse prevention ③ Lifestyle change ④ Harm reduction
Stabilisation
Abstinence (detoxification)
Most people experience withdrawal symptoms if they go without heroin or opioids. Withdrawal symptoms such as muscle aches, stomach cramps and vomiting, insomnia, dysphoria start in the first 24hrs and may get worse for 1-2 days before subsiding. Opiate withdrawal is not necessarily severe nor is it life threatening.
Most people opt for a medically assisted detoxification. Buprenorphine (Subutex™️ Suboxone™️) is a useful medication in that it can be used for detoxification either from heroin or to switch as an opiate substitute. Lofexidine (Britlofex™️) suppresses withdrawal symptoms and is used alongside symptomatic medication for stomach cramps and muscle aches and insomnia.
The withdrawal from methadone can be unpleasant and last for several weeks: it is best to switch to buprenorphine for detoxification.
Substitution
Opiate substitution medication is an appealing quick fix for opiate dependence. It is easy to deliver and usually results in rapid improvement; however, beware of accepting substitution as all there is to treatment - lifestyle change is invariably the key to long term success. Substitute medication should be steadily reduced in step with the client’s improving social support and stability. For clients who are unable to achieve abstinence despite all possible efforts by their practitioners, then a maintenance prescription may be beneficial.
Heroin is converted to something called 6-mono-acetyl morphine (6MAM) within a few minutes. 6MAM is detectable in urine for less than a day. It is converted to morphine which can be detected for up to 3 days.
Substitute medications
Buprenorphine (Subutex™️ Suboxone™️) has less of an opiate effect than other substitutes but a much better safety profile; it is also available as a depot (Buvidal™️). Methadone has the longest history of use as a substitute. It has a definite opioid effect, and so is liked by addicts, but it is long acting causing withdrawal symptoms to be prolonged and methadone is experienced as difficult to get off. Diamorphine (heroin) is only prescribed in very particular circumstances - it is difficult to control diamorphine use just as it is with illicit heroin.
Relapse prevention
The strong craving for opioids and pressure from drug dealers to keep their ‘customers’ addicted make it difficult for people dependent on opioids to abstain or moderate its use. What might trigger further use?
in the short term
underestimating the length of time feeling unwell
a lack of comfort food and comfort activities
forgetting to destroy contact details of drug dealers
in the long term
personal high risk situations
Rating high risk situations is the first task in a relapse prevention programme. Once identified and rated for the degree of temptation and the individual’s belief in their coping ability, new coping strategies can be identified, practised and implemented in real life. Guidance on implementing a relapse prevention intervention can be found in the iSBNT manual page30.
Relapse prevention medication...
▷ Naltrexone (Nalorex™) blocks the effects of taking heroin or other opiates.
It will cause severe withdrawal if taken with opiates in the blood | effective if supervised
▷ Naltrexone depot long acting forms of naltrexone have limited availablity subject to medicines regulations | effective without supervision
Where methadone, buprenorphine or other opioids are used for maintainance prescribing it becomes a moot point whether they constitute a relapse prevention or harm reduction medication.
Lifestyle change
It is only feasible to get on with the challenge of lifestyle change, which may include sorting out mental health issues, once a person has some control of their opioid use, which can be quick to achieve. We believe social treatments are most likely to be effective, not just for problem users but also for their family and friends, but other approaches can be effective provided that they are well structured and well delivered. Guidance on addressing lifestyle change can be found in the iSBNT manual page 41. The recovery tasks are all about making lifestyle changes.
Even with the most positive therapist and the optimal treatment, a number of opioid users find it too difficult to give up drugs, in which case a switch to a maintenance prescription can facilitate lifestyle changes. This should be a positive decision rather than something to drift into. It implies reducing the intensity of any psychosocial intervention, making contact much less frequent and minimising monitoring of the prescription. Substitute prescribing has potential for both costs, which tend to accumulate over time, and benefits, which are particularly strong in the early stages of substitution…
some pros
✔︎ Reduced mortality especially in early days
✔︎ Reduced use of illicit drugs and related crime
✔︎ Space to make necessary lifestyle changes
✔︎ Reduced injecting and related spread of blood borne viruses
✔︎ Improved diet and general health
✔︎ Psychological health improved
✔︎ Relationships including parenting improved
✔︎ Reduced drug debris on the streets
✔︎ Incentive to engage with behaviour change treatment
✔︎ Less exposure to other drug users
✔︎ Dispensing arrangements impose some structure
some cons
✘ Significant annual health care costs
✘ Maintaining opiate dependence and its problems
✘ Maintaining drug using career and its problems
✘ Continuing involvement with other drug users
✘ Impaired social functioning: work, relationships, parenting
✘ Steady decline in physical health
✘ Monitoring interferes with leading a ‘normal’ life
Harm reduction
Generic harm reduction measures to improve health and wellbeing are to be applied throughout treatment. Opioid users may also be injectors which is a high risk behaviour from a health perspective and risk of overdose. Be aware of local needle exchange schemes, make available naloxone (a drug which reverses opiate effects - may need repeating for longer acting opioids), and ensure take up of all immunisations. Take a look at the Harm and Harm Reduction slides on the How do drugs work? page.
