Heroin detoxification

When used as a cough suppressant, methadone is taken in a liquid or tablet form in very small (1-2 mg) doses every four to six hours. For relief of moderate to severe pain, it is generally given as a tablet or as an intramuscular injection, 2.5-20 mg every three to four hours. When used in heroin detoxification and methadone maintenance programs, it is given as oral tablets, biscuits, or liquid, 20-120 mg every 24-48 hours. 

Detoxification is more successful when the patient is transitioned from a stable methadone dose with the support of ongoing therapy than when the patient comes directly from the street for detoxification from heroin. Some practitioners believe that detoxification with clonidine can be more rapid than with methadone, at least on an outpatient basis. One important hmitation of clonidine is that, although it suppresses autonomic signs of withdrawal, subject-reported symptoms, such as lethargy, restlessness, insomnia, and craving, are not well relieved (Charney et al. 1981 Jasinski et al. 1985). Anxiety may... 

Kleber HD, Weissman MM, Rounsaville BJ, et al Imipramine as treatment for depression in addicts. Arch Gen Psychiatry 40 649-633, 1983 Kleber HD, Riordan CE, Rounsaville BJ, et al Clonidine in outpatient detoxification from methadone maintenance. Arch Gen Psychiatry 42 391-394, 1983 Kleber HD, Topazian M, Gaspari J, et al Clonidine and naltrexone in the outpatient treatment of heroin withdrawal. Am J Drug Alcohol Abuse 13 1-17, 1987 Kornetsky C. Brain stimulation reward, morphine-induced stereotypy, and sensitization implications for abuse. Neurosci Biobehav Rev 27 777-786, 2004 Kosten TR, Kleber HD Buprenorphine detoxification from opioid dependence a pilot study. Life Sci 42 633-641, 1988... 

O Connor PG, Carroll KM, Shi JM, et al Three methods of opioid detoxification in a primary care setting a randomized trial. Ann Intern Med 127 526-530, 1997 Oppenheimer E, Tobutt C, Taylor C, et al Death and survival in a cohort of heroin addicts from London clinics a 22-year follow-up study Addiction 89 1299—1308, 1994... 

Seecof R, Tennant FS Subjective perceptions to the intravenous rush of heroin and cocaine in opioid addicts. Am J Drug Alcohol Abuse 12 79—87, 1987 Sees KL, Delucci KL, Masson C, et al Methadone maintenance vs. 180-day psycho-socially enriched detoxification for treatment of opioid dependence a randomized controlled trial. JAMA 283 1303-1310, 2000 Sells SB Treatment effectiveness, in Handbook on Drug Abuse. Edited by Dupont RE, Goldstein A, O Donnell J. Washington, DC, U.S. Government Printing Office, 1979, pp 105-118... 

Umbricht A, Hoover DR, Tucker MJ, et al Opioid detoxification with buprenorphine, clonidine, or methadone in hospitalized heroin-dependent patients with HIV infection. Drug Alcohol Depend 69 263-272, 2003 Villagomez RE, Meyer TJ, Lin MM, et al Post-traumatic stress disorder among inner city methadone maintenance patients. Subst Abuse Treat 12 253—257, 1995 Mining E, Kosten TR, Kleber H Clinical utility of rapid clonidine-naltrexone detoxification for opioid abusers. Br J Addict 83 567-575, 1988 Washton AM, Pottash AC, Gold MS Naltrexone in addicted business executives and physicians. J Clin Psychiatry 45 39 1, 1984 Wesson DR Revival of medical maintenance in the treatment of heroin dependence (editorial). JAMA 259 3314-3315, 1988... 

Cross-tolerance A condition where an individual who is tolerant to the pharmacological effects of one member of a drug family also shows tolerance to other members of that family. Cross-dependence allows drug substitution during detoxification (e.g., methadone for heroin or clomethiazole for ethanol), so reducing the severity and potential danger of withdrawal symptoms. 

Keen J, Oliver P, Rowse G and Mathers N (2000). Keeping families of heroin addicts together Results of a thirteen months intake for community detoxification and rehabilitation at a Family Centre for drug users. Family Practice, 17, 484 -89. 

Unnecessary detoxification with drugs should be avoided if possible (e.g., if symptoms are tolerable). Heroin withdrawal reaches a peak within 36 to 72 hours, and methadone withdrawal peak is reached at 72 hours. 

Methadone (Dolophine). For over 30 years, methadone has been the mainstay of treatment for opiate dependence. A replacement therapy, methadone has been used both for detoxification and for long-term maintenance. It has a slower onset of action and is longer acting than other narcotic analgesics. It causes little of the euphoria produced by drugs such as heroin. 

Michael is a 30-year-old man who has been a patient in our methadone clinic for three years. He has a ten-year history of opiate use in all, but previous treatment had been elsewhere on a detoxification basis. At one time he had strongly wished to come off drugs completely and went into a residential rehabilitation centre, but although he completed the stay satisfactorily he relapsed into heroin use soon afterwards. It is now agreed between us that his methadone treatment will need to continue long-term. 

Further situations in which methadone can seem an unsatisfactory substitution agent are towards the other end of the treatment spectrum. In uncomplicated maintenance treatment or for detoxification, the criticisms which are levelled at methadone relate not so much to the subjective effects, but to the aspects of addictiveness, abuse potential and toxicity. The issue of whether methadone is too addictive to be really suitable for detoxification is considered in detail in Chapter 3, and the controversial subject of methadone risks and deaths in Chapter 1. It is in the relatively milder cases of heroin dependence that buprenorphine treatment as an alternative to methadone has risen to great prominence in several countries, although, importantly, the condition definitely does not have to be mild for this medication to be used. Undoubtedly the introduction of buprenorphine is one of... 

Table 3.1 Features desirable for quick community detoxification from heroin...

Lee attended for a short series of counselling appointments to do the preparatory work for a detoxification. His parents had become aware of the problem, and after initial distress they were keen to help him through his treatment With the counsellor s advice, Lee reduced his heroin use to the minimum which he needed to stop him withdrawing, and it was arranged that he had our standard detoxification regime of lofexidine and additional symptomatic medication. He had taken a week off work to do the detoxification, and daily home visits were undertaken. 

Lee s progress through the detoxification was uneventful, with poor sleep the most troublesome aspect. He was pleasantly surprised with the low level of withdrawal discomfort, compared to his own attempts to come off heroin without medication. He and his parents followed the instructions carefully, and in all Lee used about three-quarters of the available medication, apart from the sleeping tablets, which were all necessary. Nine days after his last use of heroin naltrexone was instituted, with no withdrawal reaction. 

Jane had unsuccessfuily attempted detoxification with lofexidine about six months previously. At the time she had been keen to have this method and then go on naltrexone, but the main problem had been that she was unable to satisfactorily reduce her heroin use in preparation. She also had the ongoing stresses of child care, although she had had some help offered. 

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