Achieving detoxification and abstinence

Individuals who are more heavily dependent on opiates clearly also require detoxification at various stages, and the remainder of the chapter discusses other forms of withdrawal treatment. As indicated in Chapter 1, community detoxification with methadone, as opposed to maintenance, is not well supported by evidence, but nevertheless this has been a standard treatment in the UK and other countries for many years. Meanwhile the almost certainly milder withdrawal symptoms from buprenorphine make this a more attractive proposition than methadone in detoxification, and the major impact made recently by this treatment will be examined. The last section discusses relapse prevention, focusing on counselling approaches and on the use of the opiate antagonist naltrexone, which we recommend after most detoxifications from opiates. 

Quick detoxification is a concentrated treatment approach, which requires motivation and organization on the part of both the drug user and the drug team worker. It is important not to attempt the treatment in unsuitable cases, and selection must be based 

Information on the withdrawal process is provided, along with schedules for the detoxification medications, and the treatment is also explained to anyone else who will be involved. Importantly, the detoxification takes place when the worker can fit in home visits through the period, preferably every day, and so it is not usually suitable to start a detoxification at a weekend. Given a well-organized service with competent drug workers. 

Individuals on very small amounts of heroin are prescribed diazepam for anxiety, agitation or craving, zopiclone or zolpidem for insomnia, hyoscine butylbromide (Buscopan) for stomach cramps, and diphenoxylate/atropine (Lomotil) for diarrhoea, over a seven-day period. The medication schedule provided to the user explains which drug is for which symptoms, and the maximum doses of each that can be taken in a day, which for diazepam varies during the course. The basic medication regime is included in the Appendix. 

The evidence for effectiveness of lofexidine initially relied on the similarity with clonidine, without the same risk of hypotension, but there have increasingly been controlled studies of lofexidine itself (Bearn et al. 1996, Khan et al. 1997, Lin et al. 1997). The better toleration and somewhat broader effectiveness of lofexidine was demonstrated in a randomized study against clonidine (Gerra et al. 2001), while the need for some adjunctive medications is suggested by experimental studies (Walsh et al. 2003) as well as clinical experience. 

---

Naltrexone (ReVia). Naltrexone is a very potent antagonist of the actions of opiates. It has been used to reduce the rewarding effects of not only opiates but alcohol as well. Like buprenorphine, naltrexone appears to reduce craving for opiates by blocking their pleasurable effects. Naltrexone is not useful for detoxification and in fact worsens withdrawal. Naltrexone can be useful for maintenance treatment in those patients motivated to achieve total abstinence. It is taken at a constant dose of 50mg/day. A sustained-release depot formulation currently under development will likely help to overcome adherence issues that often undermine treatment for substance use disorders. 

The efficacy of acamprosate in promoting abstinence has not been demonstrated in subjects who have not undergone detoxification and not achieved alcohol abstinence prior to beginning acamprosate treatment. The efficacy of acamprosate in promoting abstinence from alcohol in polysubstance abusers has not been adequately assessed. 

Withdrawal from nicotine is treated in the outpatient setting. Symptomatic detoxification from nicotine is achieved with any single or combination of NRTs. Additional nonnicotine medications such as bupropion, nortriptyline, and clonidine may be helpful to reduce craving and various other withdrawal symptoms. Including a behavioral therapy component increases abstinence rates when combined with pharmacologic treatment. 

Detoxification] should be considered successful if safe and comfortable withdrawal has been achieved, whether or not this is followed by a permanent state of abstinence. The ultimate achievement of abstinence, if that should happen, should be regarded as a bonus... detoxification should therefore be regarded as very different from other forms of treatment, and possibly should not even be considered to be a form of treatment. 

---