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Treating opiate addiction, Part I: Detoxification and maintenance

Treating opiate addiction, Part I:
Detoxification and maintenance

(This article was first printed in the December 2004 issue of the Harvard Mental Health Letter. For more information or to order, please go to www.health.harvard.edu/mental.)

Opiates are outranked only by alcohol as humanity’s oldest, most widespread, and most persistent drug problem. Although law enforcement, psychiatry, and pharmacological science have been seeking solutions for over a century, more than one million opiate addicts remain in the United States alone. Still, in recent years new drug treatments and refinements of older psychological and social therapies are offering some hope of relief.

Dozens of opiates and related drugs (sometimes called opioids) have been extracted from the seeds of the opium poppy or synthesized in laboratories. The poppy seed contains morphine and codeine, among other drugs. Synthetic derivatives include hydrocodone (Vicodin), oxycodone (Percodan, OxyContin), hydromorphone (Dila-udid), and heroin (diacetylmorphine). Some synthetic opiates or opioids with a different chemical structure but similar effects on the body and brain are propoxyphene (Darvon), meperidine (Demerol), and methadone. Physicians use many of these drugs to treat pain.

Opiates enhance the effects of the neurotransmitters called endorphins and enkephalins by acting at nerve receptors for these natural body chemicals. They suppress pain, reduce anxiety, and at sufficiently high doses produce euphoria. Most can be taken by mouth, smoked, or snorted, although addicts often prefer intravenous injection, which gives the strongest and most immediate pleasure.

Opiates do not have serious side effects at therapeutic doses, although they can cause constipation and depress breathing. Addicts neglect their health and safety for many reasons, including a tendency to ignore pain and other normal physical warning signals. The use of intravenous needles can lead to infectious disease, and an overdose, especially taken intravenously, often causes respiratory arrest and death.

Addicts take more than they intend, repeatedly try to cut down or stop, spend much time obtaining the drug and recovering from its effects, give up other pursuits for the sake of the drug, and continue to use it despite serious physical or psychological harm. Some cannot hold jobs and turn to crime to pay for illegal drugs. Heroin has long been the favorite of street addicts because it is several times more potent than morphine and reaches the brain especially fast, producing a euphoric rush when injected intravenously. But prescription opiate analgesics, especially oxycodone and hydrocodone, have also become a problem.

In anyone who takes opiates regularly for a long time, nerve receptors are likely to adapt and begin to resist the drug, causing the need for higher doses. The other side of this tolerance is a physical withdrawal reaction that occurs when the drug leaves the body and receptors must readapt to its absence. This physical dependence is not equivalent to addiction. Many patients who take an opiate for pain are physically dependent but not addicted: The drug is not harming them, and they do not crave it or go out of their way to obtain it.

Treating addicts is not easy. Even recognizing and acknowledging the need is difficult, because addicts conceal, rationalize, and minimize, while friends and family may fear being intrusive or having to assume responsibility. The addiction is a chronic disease with no lasting inexpensive cure. Recovery, when it occurs, is precarious, and relapse is a constant danger.

Detoxification

For some addicts, the beginning of treatment is detoxification — controlled and medically supervised withdrawal from the drug. (By itself, this is not a solution, because most addicts will eventually 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 tend to produce more intense but briefer symptoms. The effect of a single dose of heroin, a relatively short-acting drug, lasts 4–6 hours, and the withdrawal reaction lasts for about a week.

No single approach to detoxification is guaranteed to be best for all addicts. Many heroin addicts 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.

OxyContin

OxyContin is a prescription painkiller that contains the opiate oxycodone in a capsule that releases the drug slowly over a period of 12 hours. Since its introduction in 1995, OxyContin has become popular with abusers and addicts. It is stolen and diverted to the illicit market or dissolved in water for snorting or injection. (Chemists are working on a capsule that will be more difficult to tamper with.)

The vast majority of patients who take prescription opiate analgesics do not become addicted. Although OxyContin is already a controlled substance, further restrictions are being imposed and pharmacies have begun refusing to stock it. Some physicians are worried about the effect on medical practice. The National Foundation for the Treatment of Pain insists that OxyContin abuse is a minor problem, but others think that the campaign for better pain treatment has led some doctors to prescribe opiates too freely.

The patients most susceptible to OxyContin addiction are those with a history of alcohol or drug abuse or addiction. Prescribing opiate analgesics to these patients is legal, but physicians have to be aware of the problem and try to determine whether the patient is likely to use the drug responsibly. They should watch for a tendency to shop for doctors, seek early refills, or try to obtain the drug from more than one source. More serious problems are deterioration in work and family life, forged prescriptions, repeatedly “lost” or “stolen” prescriptions, refusing referrals to specialists, and abuse of alcohol and illicit drugs. (In patients taking opiate analgesics regularly, some tolerance and physical dependence are to be expected, and by themselves should not be regarded as signs of addiction.) Patients who require long-term treatment with OxyContin or other opiate analgesics may want to have a talk with their doctors if they find that they are no longer judging their need for the medicine solely by the severity of their pain.

Methadone maintenance

Since the 1970s, professionals who care for opiate addicts have reluctantly recognized that many of them will not or cannot stop taking the drug. The solution is maintenance — dispensing opiates under medical supervision. More than 100,000 American addicts are now using methadone as a maintenance treatment. Although it is still politically controversial, this practice has better scientific support than any other treatment for any kind of drug or alcohol addiction.

Because there is a risk of diversion to the illicit market, addicts must come to specialized clinics for methadone, which they take daily in liquid form. A single dose lasts 24–36 hours, and there are few side effects. Some methadone clinics also provide other services, including vocational and educational aid, referrals to other medical and social service agencies, help for the families of addicts, and treatment for cocaine or alcohol abuse.

Addicts who switch from illicit opiates to methadone avoid the highs and lows and the medical risks of intravenous injection and the criminal behavior that supports it. Studies show that they are less depressed, more likely to hold a job and maintain a family life, less likely to commit crimes, and less likely to contract HIV or hepatitis. Methadone can be continued indefinitely, or the dose can be gradually reduced in preparation for withdrawal. It has been estimated that about 25% of patients eventually become abstinent, 25% continue to take the drug, and 50% go on and off methadone repeatedly.

Buprenorphine

A promising approach to maintenance is the partial opioid agonist buprenorphine. This drug is taken three times a week as a tablet held under the tongue. It occupies opiate nerve receptors and produces a mild opiate-like effect. At higher doses, it continues to produce the same weak effect while displacing more potent drugs. In a person who is physically dependent on opiates, buprenorphine causes a withdrawal reaction. There is some risk of abuse if the tablet is dissolved and injected, so buprenorphine has been made available in combination with the short-acting opiate antagonist naloxone, which has little effect when absorbed under the tongue but neutralizes the effect of injected opiates.

The main advantage of this combination, sold under the name Suboxone, is that patients do not have to come to clinics to take it, because there is no illicit market and no danger of diversion. Since 2002, individual physicians with proper training and certification have been allowed to prescribe buprenorphine in their offices for patients to take home. It could be a solution for opiate addicts who will not or cannot attend a methadone clinic because of the inconvenience, the stigma, or a long waiting list. And switching some addicts to buprenorphine could free places in methadone clinics for others.

Heroin maintenance

The idea of maintaining addicts on injected drugs is an old one. Morphine maintenance was attempted for a few years in the United States in the 1920s, and it continued on a small scale in Great Britain until 1968. Since the mid-1990s, European researchers have been experimenting with heroin maintenance for addicts who do not respond to other treatments. They claim good results, which critics have questioned. Injectable drug maintenance is not allowed in the United States, and its prospects are doubtful.

Resources

American Society of Addiction Medicine
301-656-3920
www.asam.org

Buprenorphine Information Center
866-287-2728 (toll free)
www.buprenorphine.samhsa.gov

Narcotics Anonymous World Services
818-773-9999
www.na.org

National Institute on Drug Abuse
301-443-1124
www.drugabuse.gov

Smart Recovery
866-951-5357 (toll free)
www.smartrecovery.org

Substance Abuse and Mental Health Services Administration (SAMHSA)
800-662-4357 (toll free)
http://findtreatment.samhsa.gov/

References

DiClemente C, et al. “Readiness and Stages of Change in Addiction Treatment,” American Journal on Addictions (March–April 2004): Vol. 13, No. 2, pp. 103–19.

Fudala PJ , et al. “Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone,” New England Journal of Medicine (Sept. 4, 2003): Vol. 349, No. 10, pp. 949–958.

Gabbard GO, ed. Treatments of Psychiatric Disorders, Second Edition. American Psychiatric Press, 1995.

Kleber HD. “Pharmacologic Treatments for Heroin and Cocaine Dependence,” American Journal on Addictions (2003): Vol. 12, Suppl. 2, pp. S5–S18.

Lowinson JH, et al. eds. Substance Abuse: A Comprehensive Textbook, Third Edition. Williams and Wilkins, 1997.

van den Brink W, et al. “Management of Opioid Dependence,” Current Opinion in Psychiatry (2003): Vol. 16, pp. 297–304.

(This article was first printed in the December 2004 issue of the Harvard Mental Health Letter. For more information or to order, please go to www.health.harvard.edu/mental.)

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