Opioid
DependenceWithdrawal: characterized by extreme discomfort, usually with abdominal cramps, piloerection, diarrhea, and the feeling of having a severe flu. Although uncomfortable, opioid withdrawal is rarely life-threatening. The neurobiology of withdrawal is that it stems from overactivity of the locus ceruleus.
Detoxification: if a patient is stuporous or having respiratory difficulties because of an overdose, naltrexone, an opioid antagonist, can be used to reverse the effects of the opioids. Do not use this in someone who is actively withdrawing, as it will worsen the withdrawal.
Clonidine is helpful in reversing the hypertension, tachycardia, and sympathetic excess often seen in opioid withdrawal.
Benzodiazepines may also be helpful in decreasing the patient's anxiety and discomfort, and may also help treat the patient's muscle cramps.
Methadone may also be used in detoxification (although it is more commonly used in maintenance therapy) as a taper (25-30 mg po qd x 1 day, then 15 mg po qd, then 10 mg po qd, then 5 mg po qd). Never use more than 35 mg po qd of methadone for detoxification (more may be used for maintenance, however).
Medical Comorbidity: always have a high index of suspicion for HIV, Hepatitis B and C, and other illnesses that may result from IV drug use, if that is the patient's route of administration. Ask about needle sharing, cleaning of needles with Chlorox, and give them psychoeducation about risk factors for HIV. Also, many substance abusers will mix promiscuous, unprotected sexual intercourse with drug use (less true for heroin than for substances such as cocaine), so insure you inquire about this also and make condoms available to your patients. Also consider nutritional issues, hydration issues, and other illnesses that maybe seen in particular among the homeless population, such as tuberculosis (they should be skin tested with the PPD once a year - ask when their last test was or you will get a false positive if you test too soon after their last PPD was placed).
Maintenance Therapy: Methadone is most commonly used for maintenance, the rationale being that methadone will stimulate opioid receptors enough to stave off craving, but not so much that the patient experiences intoxication. In fact, if one uses heroin while on methadone, the "high" one experiences from heroin will either be completely blocked or greatly ameliorated. Note that methadone maintenance is the treatment of choice for a pregnant woman with opioid dependence.
Studies show that methadone is most effective if used in doses greater than 80 mg po qd. In other words, those patients randomized to receive less than this amount were far more likely to relapse than those receiving 80 mg or more. Those receiving less than 60 mg po qd were particularly prone to relapse. This is true not only for heroin relapse, but also for cocaine, when methadone is used in high doses. The rationale seems to be that less than 60 mg of methadone will not adequately reduce craving and microwithdrawal, so that the patient is very likely to "supplement" the methadone with some street heroin.
LAAM (Levo Alpha Acetyl Methadol, also known as buprenorphine) is another useful agent that is a reduced opioid antagonist. Although still experimental (as of 1997) it is currently 6 times as expensive as methadone.
Naltrexone may be used by patients who have successfully detoxified and are afraid they might relapse. Naltrexone will block the "high" they would otherwise experience from heroin, so makes purchase of the drug either a waste of money, or if they do relapse, they will quickly ask themselves what is the point and may be more likely to return to treatment.
12 step programs such as Narcotics Anonymous, founded on the same principles as Alcoholics Anonymous, are strongly encouraged for recovery. Since most opioid dependent patients have constructed their social life around heroin, they must now recreate their social life to center around recovery. They are encouraged to attend meetings regularly - daily if need be - and to obtain what is known as a sponsor - someone with at least a year of recovery whom they can call anytime, day or night, for support, especially if they are craving or on the verge of relapse.