This article summarises the guidance on opioid detoxification from the drug misuse and dependence guidelines jointly produced by the Department of Health, the Scottish Government, the Welsh Assembly Government and the Northern Ireland Executive (last updated in September 2007),¹ as well as the National Institute for Health and Clinical Excellence (NICE) guidelines on opioid detoxification for drug misuse.² It should be read in conjunction with the separate overview article Drug Misuse and Dependence: UK Guidelines.

Introduction

• Opioid detoxification should be offered in an appropriate setting to informed opioid-dependent patients ready for, and committed to, abstinence.²
• Suitability for detoxification should be determined during the assessment process.
• The aim is for safe and effective discontinuation of opiates and minimal withdrawal symptoms.
• Detoxification usually takes about 28 days as an inpatient and up to 12 weeks in the community.
• NICE recommends that a community-based programme should be routinely offered. However, it does suggest that exceptions to this may include:
  • Those who have had previous unsuccessful community detoxification.
  • Those who need medical and nursing care due to significant mental or physical health problems.
  • Those who require complex polydrug detoxification.
  • Those who have significant social problems that may limit the success of community-based detoxification.
• Methadone, buprenorphine and lofexidine are all effective in detoxification regimens.
• Opioid detoxification should be offered as part of a package including preparation and post-detoxification support to prevent relapse.
• Psychosocial interventions (e.g. talking therapies, cognitive behavioural therapy, family therapy) and keyworking should be delivered alongside pharmacological interventions.
• If detoxification is unsuccessful, patients should have access back into maintenance and other treatment.

Suitability for detoxification

• Is the patient committed and fully informed about the detoxification process?²
  • Does the patient understand the physical and psychological aspects of opioid withdrawal and how they can be managed?
  • Does the patient understand how non-pharmacological approaches can help with withdrawal symptoms?
  • Does the patient understand the increased risk of overdose and death after detoxification if illicit drug use resumes (due to the loss of opioid tolerance; increased risk if alcohol and benzodiazepines are also used)?
• Has the high risk of relapse been explained to the patient?
• Are adequate social support networks available following detoxification?
• Is there availability of continuing professional support and treatment to maintain abstinence?

Drugs used in detoxification

Use the drug that the patient has been stabilised on. NICE states that there is no evidence that methadone or buprenorphine differ in their effectiveness during detoxification and recommends that they can both be used as first-line.³ NICE does not support the use of ultra-rapid detoxification under general anaesthetic or sedation because of the risk of serious adverse effects.

Methadone

• Stabilise the patient on methadone. Please refer to the separate article Substitute Prescribing for Opioid Dependence for further details regarding how to do this.
• Reduce the dose by about 5 mg every 1-2 weeks, aiming to achieve a dose of zero at 12 weeks.

Buprenorphine

• Stabilise the patient on buprenorphine.
• Reduce the dose by 2 mg about every 2 weeks initially.
• Reduce by 400 micrograms about every 2 weeks nearer the end of the detoxification process.

Lofexidine

• This is not a controlled drug and is a non-opioid alpha-adrenergic agonist.
• Start at 800 micrograms daily in divided doses and increase by 400-800 micrograms daily to a maximum of 2.4 mg daily in divided doses. A dose reduction is then needed.
• Treatment duration is 7-10 days but longer may be needed.
• NICE guidance states that lofexidine can be considered for detoxification in:²
  • Those who have decided not to use methadone/buprenorphine.
  • Those who want a short detoxification period.
  • Those with mild or uncertain dependence (including young people).
• Side-effects include:
  • Dry mouth
  • Sedation
  • Hypotension and bradycardia
• Daily monitoring to check blood pressure and enquire about withdrawal symptoms should take place initially.
• Other medication may be needed for opioid withdrawal symptoms such as diarrhoea and stomach cramps.

Other drugs for withdrawal symptoms

Evidence that any of these drugs improve outcome is lacking.

• Diarrhoea: loperamide 4 mg immediately followed by 2 mg after each loose stool for up to 5 days; usual dose 6-8 mg daily, maximum 16 mg daily.
• Nausea, vomiting and stomach cramps: metoclopramide 10 mg every 8 hours or prochlorperazine 5 mg tds or 12.5 mg IM 12-hourly.
• Stomach cramps: mebeverine 135 mg tds.
• Agitation, anxiety and insomnia: diazepam up to 5-10 mg tds prn or zopiclone 7.5 mg nocte if previously benzodiazepine-dependent.
• Muscular pains and headaches: paracetamol and non-steroidal anti-inflammatory drugs or topical rubefacients.

The use of naltrexone for relapse prevention

• Naltrexone is an opioid antagonist. It can block a former opiate user from experiencing the effects of opiates when taken regularly. Therefore, it can be helpful in maintaining abstinence following detoxification.
• NICE supports the use of naltrexone.⁴ The guidance advises:
  • Naltrexone can be considered as a treatment option in people who have previously been opioid-dependent and are highly motivated to remain abstinent after detoxification.
  • It should be given as part of a programme of supportive care.
  • Patients should be fully informed of its potential adverse effects.
  • Its effectiveness should be regularly reviewed and it should be discontinued if there is evidence of opioid misuse.

Document references

1. Drug Misuse and Dependence - UK Guidelines on Clinical Management, Dept of Health (September 2007)
2. Drug misuse: opioid detoxification, NICE Clinical Guideline (2007)
3. Drug misuse - methadone and buprenorphine, NICE Technology Appraisal Guidance (2007)
4. Drug misuse - naltrexone, NICE Technology Appraisal Guidance (2007); Naltrexone for the management of opioid dependence

Acknowledgements