Other laboratory tests.
For some people with opioid use disorder (the new terminology instead of addiction), the beginning of treatment is detoxification — controlled and medically supervised withdrawal from the drug. (By itself, this is not a solution, because most people with opioid use disorder resume taking the drug unless they get further help.) The withdrawal symptoms — agitation; anxiety; tremors; muscle aches; hot and cold flashes; sometimes nausea, vomiting, and diarrhea — are not life-threatening, but are extremely uncomfortable. The intensity of the reaction depends on the dose and speed of withdrawal. Short-acting opiates, like heroin, tend to produce more intense but briefer symptoms.
Although the public health effort was well intentioned, the consequences are now very well recognized. Overuse of prescription opioids has been a major contributor to the current “opioid epidemic.”
There is high prevalence of comorbid psychiatric and substance abuse disorders among opioid addicts, as well as diseases common because of drug lifestyle, eg, acquired immune deficiency syndrome (AIDS), hepatitis B or C, and tuberculosis. 87 Since treatments for HIV and hepatitis C can stabilize these disorders, methadone programs need to screen and refer patients for medical treatment, as well as providing or referring for psychiatric disorders if patients are to adequately recover.
The Food and Drug administration (FDA) approved sublingual buprenorphine in 2002 for office-based treatment for detoxification or maintenance of opioid dependence. Buprenorphine is long-acting, safe, and effective by the sublingual route, but may precipitate withdrawal symptoms if given too soon after an opioid agonist. If the patient has withdrawal symptoms and has waited at least 12 hours after short-acting opioids and 36 hours after methadone, buprenorphine usually serves to relieve these symptoms and is less likely to precipitate withdrawal It may also be useful in emergency department settings. 11 Heroin detoxification is managed by administering buprenorphine 2 to 4 mg sublingually after the emergence of mild-to-moderate withdrawal. A second dose of buprenorphine 2 to 4 mg may be administered approximately 1 to 2 hours later, depending on the patient's comfort level. Usually a total of 8 to 12 mg of buprenorphine is sufficient the first day. For most patients, a slow taper over a week or so is a safe and well tolerated strategy. Any buprenorphine dose that worsens withdrawal symptoms suggests the buprenorphine dose is too high compared with the level of withdrawal. The symptoms should be treated with clonidine, and further buprenorphine doses withheld for at least 6 to 8 hours. Buprenorphine, even at doses of 16 mg, may not suppress all signs and symptoms of withdrawal if the patient had a very severe habit, 12 but most symptoms respond to adding clonidine 0.1 mg every 4 to 6 hours.
Treating opiate addiction, Part I: Detoxification and maintenance.
Although naltrexone affects a variety of endocrine functions, 169-172 such effects have not been associated with particular problems. Likewise, although upregulation of opioid receptors has been reported in rodents, it was not found in a human study. Thus, the main risk of heroin overdose post naltrexone appears to be from loss of tolerance. 148.
No single approach to detoxification is guaranteed to work well for all patients. Many regular heroin users are switched to the synthetic opiate methadone, a longer-acting drug that can be taken orally or injected. Then the dose is gradually reduced over a period of about a week. The anti-hypertensive (blood pressure lowering) drug clonidine is sometimes added to shorten the withdrawal time and relieve physical symptoms.