Information ⬇
Editors
Treatment of Drug Addicts
Essentials
- It is essential to recognize addiction (alcohol, drugs) Recognition of Alcohol and Drug Abuse and always act professionally and pertinently, see Providing Care for an Alcohol or Drug Abuser.
- A general practitioner may encounter a drug addict in various situations:
- An addict may also seek withdrawal or substitution therapy. Withdrawal in ambulatory care with the help of e.g. codeine, ethylmorphine or tramadol that the patient may have requested will hardly be successful. The use of buprenorphine and methadone in withdrawal substitution or maintenance therapy is defined in national legislation and/or other regulations.
- Because of the threat of spreading HIV and hepatitis C and B, the risks associated with intravenous drug use should be discussed in all contacts with addicted persons.
Common somatic diseases, symptoms and signs
- Cannabis users often have erythematous conjuctivae and oral mucous membranes.
- Opioid users have small, non-reactive pupils.
- Amphetamine users are often hyperkinetic and have hypertension and tachycardia.
- There are increasing numbers of pregnant young women who are addicted to heroin, buprenorphine, amphetamine or use a mixture of substances and who are unable to break the cycle without treatment Antenatal Clinics and Specialist Care: Consultations, Referrals, Treatment GuidelinesPregnant Substance Abuser.
- Infections ranging from infected needle punctures to endocarditis.
- Needle punctures can be found anywhere in addition to the cubital area. Patients who have used injected drugs for a long time often inject between the fingers and toes.
- Accidental injections into peripheral arteries causes necroses of the distal parts of the extremities and may even lead to amputations.
- Epidemics of hepatitis A occur among drug users.
- Hepatitis C is very common in patients who use i.v. drugs (60-80%), sometimes concomitantly with hepatitis B. In acute cases, symptoms include icterus, poor general condition and hepatomegaly. The majority of cases are asymptomatic carriers of the disease. See Viral Hepatitis.
- Trends in the incidence of HIV-infections vary from country to country.
- Central nervous system complications, rhabdomyolysis and peripheral compression damage resulting from anoxia and unconsciousness caused by overdosage.
- Toxic states induced by gamma-hydroxybutyric acid (GHB) and its precursor gamma-butyrolactone (GBL), requiring emergency care; see also Treatment of Poisoning Alcohol Poisoning.
Psychiatric diseases, symptoms and signs
- Anxiety, poor impulse control, and change of mood are common.
- Most patients who abuse drugs are also heavy drinkers. In addition to alcohol or drug abuse, personality disorders as well as mood and anxiety disorders are very common.
- There are increasing numbers of drug-dependent persons with a chronic psychiatric disorder (schizophrenia).
- Pay particular attention to psychotic symptoms.
- Massive paranoid or hallucinatory symptoms warrant treatment in a psychiatric hospital in a closed ward.
- Milder paranoid symptoms and auditory hallucinations often subside quickly and do not necessarily require antipsychotic medication, provided that the patient is familiar with these symptoms.
- Acute depression is typical when the effect of amphetamine or cocaine ceases; a more chronic depression and apathy can be associated with any drug either primarily or secondarily.
- Anxiety, sleep disorders and adverse effects of the abused drugs have made many drug addicts additionally dependent on benzodiazepines.
Examination in a health centre
- Basic blood count with platelets, CRP, ALT, ALP, GGT, serum HBsAg, hepatitis C antibodies, HIV antibodies and a urine rapid test for drugs or a broader drug screening test that also identifies the use of designer drugs.
- Codeine (antitussives containing codeine) and paracetamol-codeine combinations may give positive results in the urine test.
- Consult the laboratory regarding other possible cross-reactions.
- Other laboratory tests and x-ray as indicated by clinical signs.
- Official guidance on laboratory examinations is available at the national or regional level.
Vaccinations and infection tests and treatments
- All persons who use i.v. drugs and those in close contact with them should be given vaccinations against hepatitis A and B.
- Anonymous testing for hepatitis and HIV should be available within health care services.
- Patient groups which earlier were left without treatment for hepatitis C because of having contraindications to the therapy, such as intravenous drug users, should be referred for a therapeutic assessment, in order to determine the severity of the disease, and for treatment with new generation antiviral drugs if the severity of the liver disease warrants therapy and the patient is motivated to it.
- The price of antiviral therapy has decreased to the extent that it is no longer a reason not to treat even drug addicts.
- Local and national policies may vary.
Drug therapy
- Benzodiazepines should be avoided. It is important to diagnose possible concomitant benzodiazepine dependence and arrange treatment.
- If there is a risk of convulsions (benzodiazepine dependence, previous convulsions), carbamazepine and, for patients with hepatitis C, oxcarbazepine should be used. These drugs can also be used in the treatment of aggression problems and mood changes.
- Psychosis and anxiety caused by amphetamine or other stimulants may be treated in short-term with diazepam. Haloperidol or second-generation antipsychotic drugs are suitable for treating severe symptoms. Tachycardia and hypertension associated with amphetamine intoxication may be treated with clonidine at a dose of 75-150 µg 2-3 times daily (dampens also the withdrawal symptoms from opioids in cases of polysubstance abuse), with propranolol 20-40 mg 2-3 times daily or with labetalol 100-200 mg twice daily.
- Prefer short courses maximally 3 to 5 days of short-acting benzodiazepines. If insomnia is long lasting, prescribe melatonin or quetiapine, or levomepromazine or sedative tricyclic antidepressants provided there is a good and stable patient-doctor relationship, the patient has no liver or heart disease, and there is no uncontrolled polysubstance abuse.
- In prolonged depression citalopram and sulpiride, for example, are safe alternatives. Concomitant use of serotonin uptake inhibitors and amphetamine derivatives may lead to dangerous adverse effects.
- Withdrawal and substitution therapy in opioid-dependence, see below.
Referring to further treatment
- Acute somatic conditions are treated according to normal criteria. It is useful to discuss the possibilities of treating addiction already in this initial phase Combining Psychosocial and Agonist Maintenance Treatments for Opioid Dependence, Psychosocial Treatment for Opiate Abuse and Dependence.
- Consider referral to involuntary psychiatric evaluation if the patient is psychotic.
- In minors, serious cases of substance abuse justify compulsory care or at least child protection measures; see Substance Abuse of Adolescents.
- Treatment locations: see Providing Care for an Alcohol or Drug Abuser and local guidance
- Initial assessment considering the commencement of withdrawal or substitution therapy requires several visits to the outpatient department. The following aspects are to be considered:
- age, livelihood, housing and family relations (are there other members in the family with drug abuse problems; are there any children?)
- possible pending criminal matters
- current use of drugs, previous (documented) history of abuse and its treatments
- history of opioid withdrawals and withdrawal attempts
- verification of abuse by laboratory screening; results of other laboratory tests
- somatic and mental condition
- motivation (and reason) for treatment.
- Withdrawal treatment usually lasts for 2-4 weeks and is carried out in an institutionalized setting.
- If withdrawal treatments fail, substitution therapy should be considered. The assessment and the treatment decision are made according to the local care pathway. Later on, substitution therapy may be continued in primary care.
Withdrawal and substitution treatment of opioid addiction
- Freedom from drugs is the target; the duration of treatment is not specified.
- Buprenorphine is suitable for withdrawal in opioid dependency Buprenorfine for the Management of Opioid Withdrawal.
- A combined preparation containing both buprenorphine and naloxone (Suboxone® ) is recommended for withdrawal therapy in ambulatory care Treatment of Opiate Addiction with Sublingual Buprenorfine and Naloxone.
- The medication is started under supervision with a single dose of 2-4 mg when at least 6 hours have elapsed from the last dose of heroin. If the patient has used methadone, the time gap must be at least 24-48 hours depending on the dose.
- After the initial dose, the patient's condition should be monitored for 3-4 hours in order to recognize possible withdrawal symptoms induced by the medication (buprenorphine may trigger an opioid withdrawal state, if the patient has used a long-acting opioid during the last 24 hours).
- The maximum dose during the first 24 hours is 8 mg.
- The dose is raised during the first 3 days of therapy to 10-12 mg and the drug is discontinued over 5-8 days with dose tapering in case of opioid abuse.
- If the person seeking withdrawal has used buprenorphine for a long time, the treatment should be implemented over 1-2 months with gradual dose tapering. Buprenorphine can be started to control withdrawal symptoms and it can be used at a sufficient dose for the necessary time during the course of a somatic disease if the withdrawal symptoms aggravate the patient's clinical condition and impede therapy (refer to local legislation).
- Clonidine Adrenergic Agonists Alone and in Combination with Opioid Antagonists for the Management of Opioid Withdrawal or lofexidine (special permission for compassionate use may be required) Adrenergic Agonists Alone and in Combination with Opioid Antagonists for the Management of Opioid Withdrawal can be used
- to control opioid withdrawal symptoms in mild opioid dependency, for example, in adolescents aged below 18 years with a short history of opioid use
- to control withdrawal symptoms triggered by buprenorphine on initiation of the medication when the patient has been using methadone or some other long-acting opioid agonist
- in the discontinuation phase of withdrawal using buprenorphine if the symptoms become too aggravated
- to control the possible activation of withdrawal symptoms when the patient transfers from buprenorphine to naltrexone Adrenergic Agonists Alone and in Combination with Opioid Antagonists for the Management of Opioid Withdrawal.
- The starting dose of clonidine is 0.075 mg × 2-4. The maximum daily dose is 1-1.2 mg. Monitoring of blood pressure is essential.
- Lofexidine does not lower blood pressure as easily as clonidine and the patients appear to approve the drug better. The dose is 1-2 tablets administered 2-3 times daily up to a dose of 12 tablets daily (2.4 mg).
- The duration of pharmacotherapy required in heroin withdrawal is 7-10 days. The therapy is continued for 2-3 weeks for the symptoms of the tapering phase of buprenorphine. With both clonidine and lofexidine additional drugs are needed: anti-inflammatory analgesics, levomepromazine in low doses, often also loperamide for diarrhoea and low doses of benzodiazepines.
- Successful withdrawal of opioids without substitution therapy is highly unlikely if the dependency has become chronic. Buprenorphine can be used for short-term (less than a year) substitution therapy where the aim is withdrawal. This treatment option is suitable for those patients who have used buprenorphine for years for self-medication and have developed a wish to try complete withdrawal. If withdrawal even with a slow schedule fails, the drug should be continued as substitution therapy.
- Substitution therapy is nowadays considered as the first line therapy for opioid addiction.
- Substitution therapy can be started if withdrawal treatment for opioid dependence has failed. The target is rehabilitation or freedom from drugs, or reduction of harms and improvement of quality of life. The specialized unit assessing the need and starting the therapy should have qualified staff and other prerequisites for providing appropriate therapy. National legislation or other regulations may apply and should be checked.
- Buprenorphine-naloxone combination (Suboxone® ) Treatment of Opiate Addiction with Sublingual Buprenorfine and Naloxone or methadone can be used for substitution Methadone Maintenance Therapy for Opioid Dependence.
- When used for substitution, buprenorphine is started as in withdrawal (see above). The dose is raised according to response by 2-8 mg per day up to the optimal treatment range of 12-24 mg. If the patient has regularly used more than 8 mg of injectable buprenorphine per day, the first-day dose may be higher than 8 mg.
- Good compliance is achieved with daily buprenorphine doses of 16-24 mg (maximum daily dose 32 mg). Moderate doses of methadone have been found to be equally effective as high doses of buprenorphine. If high-dose buprenorphine (16-32 mg/day) is not sufficient to abolish the craving for opioids, compulsive injecting of buprenorphine or withdrawal symptoms, methadone is a better alternative Buprenorphine Versus Methadone for Opioid Dependency.
- The patient's craving for opioids, withdrawal symptoms before the next dose and possible concomitant use of injected substances are followed up.
- Possible benzodiazepines use that has accumulated over time is gradually discontinued when the optimal range of substitution has been achieved. If benzodiazepines have been used in very high doses, they may cause sedation when the buprenorphine dose is raised. Therefore the benzodiazepine level should be decreased and the dose stabilized to the minimum level tolerated by the patient, and the speed of buprenorphine dose increments must be reduced.
- If the discontinuation repeatedly fails, it is warranted to continue benzodizepine medication with a low dose, for example oxazepam, as long as the safety of the pharmacotherapy is not endangered.
- Methadone medication is started with 10-20 mg following up the patient's condition. During the first 24 h the maximum dose is 30-40 mg. The dosage is raised by 5 mg per day up to the daily dose of 50 mg, after which the interval between dose increments is prolonged to 3-7 days according to response.
- Remember that unlike buprenorphine, methadone is a toxic substance and the dose increments lead to stabilization level only in one week.
- With methadone, the level of medication corresponding to high-dose buprenorphine is reached with 60-80 mg.
- However, in the majority of patients methadone tolerance develops gradually over the first treatment weeks after the stable phase has been achieved, causing withdrawal symptoms and necessitating dose increments.
- In long-term therapy the dose of methadone is tailored individually, however, a large group of patients manages well with 80-120 mg daily.
- Substitution is usually given under supervision.
- Depending on the legislation of each country, the patient may also be given doses for administration at home. This can take place when parallel use of opioids or other drugs has ceased, the right dosage has been established, the patient feels well and he/she has learnt to visit the therapy unit at scheduled times.
- Home administration is usually started on weekends and the amount of doses given to the patient is gradually increased. If this leads to unfavourable slackening of the treatment relationship (parallel use of drugs appears, the delivered doses start to vanish etc.), monitoring should be tightened anew and supervised daily administration should be reinstituted.
- With buprenorphine, the patient can move on to supervised less frequent dispensing of the drug after about one month. Daily doses (take-home doses) to cover a maximum of eight days can be given to a compliant patient at one time (15 daily doses in exceptional cases).
- The risk of injecting combined buprenorphine and naloxone has been shown to be lower than with pure buprenorphine. Consequently, more responsibility for the correct usage can be put on the patient. If the patient is found to inject take-home doses, supervised administration of the drug should be reinstated and, if required, short institutional care applied.
- The patient should have a new medical form confirming his/her right to have the medicines in question for therapy. This form should contain dosing and storage instructions.
- In the Finnish treatment framework, if the patient's adherence to treatment is good, he/she has properly followed the instructions given with the take-home doses and he/she uses buprenorphine-naloxone combination as the substituting drug, a contract can be drawn up that allows him/her to collect the substitution medication directly from a pharmacy provided that a regular contact with the treating unit is preserved. According to the contract, the pharmacy has the right to contact the treatment unit if there are problems with the medication. Contracts between patients and healthcare practitioners may have some potential in supporting the withdrawal Contracts Between Patients and Healthcare Practitioners for Improving Patients' Adherence.
- Methadone must be stored in a locked container, as one daily dose is already lethal to an adult without tolerance to methadone.
- Injectable long-acting buprenorphine preparations are given at intervals of one week or one month. This provides the patient with a higher level of autonomy by removing the need for supervised drug administration or for "earning" the home medication. The choice of long-acting medication should be based on an individual overall therapeutic assessment, and not on the general need to improve the efficiency of treatments or to reduce negative by-products of drugs used in substitution therapies. The choice is made jointly with the patient, as is the case with any other treatment.
Physician's duty of confidentiality in drug offences
- Specific legal requirements and principles apply concerning physicians' role in drug offences and their duty of confidentiality. Such situations may concern, for example,
- the duty to report to the police imminent crimes that the physician is aware of or
- the physician's responsibility to act as a witness in the court.
- In some cases the physician may have the right to perform some action although there is no duty to perform it, while in some other cases the action may be an actual duty of a physician.
- Find out about national legislation and other relevant regulations concerning these issues.
References
- Simonsen KW, Kriikku P, Thelander G ym. Fatal poisoning in drug addicts in the Nordic countries in 2017. Forensic Sci Int 2020;313():110343. [PubMed]
- Alho H, Sinclair D, Vuori E et al. Abuse liability of buprenorphine-naloxone tablets in untreated IV drug users. Drug Alcohol Depend 2007;88(1):75-8. [PubMed]
- Simojoki K. Improving maintenance treatment of opiate addiction: Clinical aspects [Doctoral dissertation]. Helsinki University 2013 http://helda.helsinki.fi/handle/10138/38320
Related Keywords ⬆