25 - Opioid withdrawal in a community setting

Opioid withdrawal in a community setting

516 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 4 Opioid detoxification and reduction regimens Opioid maintenance can be continued for a few weeks to almost indefinitely, depending on clinical need. Some patients are keen to detoxify after short periods of stability and other patients may decide to detoxify after longer periods on maintenance prescriptions. All detoxification programmes should be part of a care programme. Given the risk of serious fatal overdose after detoxification, services providing such treatment should educate the patient about these risks and supply them with naloxone and overdose training for emergency use. In the UK, NICE guidelines state ‘dose reduction can take place over anything from a few days to several months, with a higher initial stabilisation dose taking longer to taper’ and indicate that ‘up to 3 months is typical for methadone reduction, while buprenorphine reductions are typically carried out over 14 days to a few weeks’.86 In practice, a detoxification in the community may extend over a longer period if this facilitates the client’s comfort during the process, compliance with the care plan, ­continued abstinence from illicit use during detoxification and subsequent abstinence following detoxification. Detoxification in an in-­patient setting may take place over a shorter time than in the community (e.g. 14–21 days for methadone and 7–14 days for buprenorphine) ‘as the supportive environment helps a service user to tolerate emerging withdrawal symptoms’.87 As in the community, stabilisation on a dose of a substitute opioid is first achieved, followed by gradual dose reduction, with additive medications ­judiciously prescribed for withdrawal symptoms as needed. Detoxification carries a recognised risk of relapse and fatal overdose. Therefore, if a patient is being detoxified there needs to be adequate aftercare in place, such as a ­rehabilitation programme and community support. For patients having emergency psychiatric or medical admissions, detoxification is not usually indicated unless with the support of specialist services and where aftercare arrangements are in place. Opioid withdrawal in a community setting Methadone withdrawal Following a period of stabilisation with methadone or a longer period of maintenance, the patient and prescriber may agree a reduction programme as part of a care plan to reduce the daily methadone dose. The usual reduction would be by 5–10mg weekly or every 2 weeks, although there can be variation in the reduction and speed of reduction. In the community setting, patient preference is the most important variable in terms of dose reduction and rate of reduction. The detoxification programme should be reviewed regularly and remain flexible to adjustments and changes, such as relapse to illicit drug use or patient anxieties about speed of reduction. Factors such as an increase in heroin or other drug use or worsening of the patient’s physical, psychological or social well-­being may warrant a temporary increase or stabilisation of the dose or a slowing down of the reduction rate. Towards the end of the detoxification, the dose reduction may be slower: 1–2mg per week. A longer length of stability on maintenance treatment and prolonged reduction schedules (up to a year) substantially improve the chances of achieving abstinence.88 Buprenorphine withdrawal The same principles as for methadone apply when planning a buprenorphine detoxification regimen. Dose reduction should be gradual to minimise withdrawal discomfort (Table 4.19).