Drug Detoxification revisited Dr Lucy Cockayne Consultant Psychiatrist NHS Lanarkshire

Drug Detoxification Revisited Why detox and why NOT to detox? When to detox. How to detox. – the old and the new. What is a successful detox?

Choosing the right detox “there are a multitude of treatment approaches to choose from: outpatient, inpatient, 12-step, group therapy, and the list goes on.”

“An individual can become thoroughly confused by asking a half-dozen recovering alcoholics or drug addicts how they ended their use of alcohol or drugs; the answers vary although each of them may seem convincing and emotional. They will cite such diverse approaches as hospitalization, diet, exercise, counselling, sauna's, religion, hypnosis, amino acids and self-help groups. When it comes to successful treatment, only one thing is certain: practically any approach will work for some of the people, some of the time.” To put it another way, successful treatment is like a designer suit- it's got to be tailor-made for each individual.

Who chooses? “all too often the detoxification process is ‘prescriber/cost/locality’ centred rather than client centred…. Directed to the treatment prescribing services’ preferred modal, irrespective of whether it is the most appropriate for that individual” T.S.Johnson, Addiction Biology 2003

Current situation in Scotland – a personal view Postcode lottery Little choice in detoxification options Patchy post detox support User suspicion of social service support – a reluctance to be referred.

Opiate detox – the options Broadly three types of detox: Tapering eg methadone reduction Transitional/substitution eg subutex/lofexidine Rapid opiate withdrawal using naltrexone

Ultra- rapid opiate detox 3 decades of experience Aim is to increase compfort during withdrawal Little NHS use currently Recent moves from simply detox to NIMROD- i.e.induction onto naltrexone

From UROD to NIMROD Various methods: varying from Using anaesthesia (UROD) Takes as little as 4 hours Risks of anaesthesia (some deaths) Asturian technique 6-12 hours Using sedation and early naltrexone challenge 5 day detox Variety of sedatives and side effect medications “test doses” of naltrexone followed by regular oral naltrexone Up to 98% opiate free at the end of the procedure

Heroin/methadone – full effect Gives a big buzz Leads to greater potential for dependence High risk fatal overdose Blocks only Can be used to maintain abstinence No potential for respiratory depression Helps the user feel comfortable without giving a buzz Less likely to overdose Blocks the effects of “on top” use Subutex – a difference in pharmacology Subutex – half and half Naloxone/naltrexone - blocker  receptors neurotransmission No neurotransmission  receptors effect No effect Blocks full agonists Blocks both partial and full agonists

Subutex vs lofexidine White R et al. Drug Alcohol Depend 2001; 65: Subutex = Higher completion rate Less severe withdrawal syndrome Subutexlofexidine % patients completing detoxification n = 69 P = 0.04 Two thirds One third

After detox….. No matter what detox, the risks of relapse are similar – about 90% in first 12 months. Few engage with post detox support… but here is one: Maintenance with ANTAGONISTS – ie naltrexone – worth a second look?

Naltrexone Currently available on NHS as oral treatment. Opiate antagonist: blocks μ receptors. “Therapeutic” blood levels of 2ng/ml override high dose diamorphine. Shown to be very successful in treating highly motivated patients (Washton, 1984).

Problems with oral naltrexone Washout period required before initiation of treatment. Treatment must last at least 12 months. Compliance is poor due to: Possible adverse effects e.g.dysphoria Absence of opiate induced reinforcement No adverse effects on treatment withdrawal

Improving compliance Entrusting administration to a relative or carer (Anton, 1981) Contingency contracting (Preston, 1999) Naltrexone administered by probation officers (Cornish, 1997)

Chan and Cornish Papers Chan 1996 Singapore Highly structure jail release programme NTX 3x weekly 100:100:150 75% compliance at 12 months on NTX 25% not on NTX Cornish et al 1997 USA twice weekly doses - M100:F150 NTX halved re-offending

Implants- new boy on the block 1. slow release naltrexone implants 1. 6 week (Wedgewood “Marlburg”) month (O’Neil) 2. device NOT licensed for humans: No prospect of USA licence. O’Neil licence procedure ongoing

Overview of research on implants Impact on accidental overdose in ‘high risk adolescent heroin users (Hulse 2003) report that ~600 clients have had O’ Neil implants inserted since August 2000 Looks at effects of implant on 8 ‘high risk’ adolescents “results indicate a dramatic reduction in overdose” following implant “study design does not allow causality to be imputed

Cont.. Prevention of early relapse (Foster et al 2003) looks at 2 cohorts of patients with 6 week implant 1st cohort 55, 2nd cohort 46 At 12 weeks 21-26% resumed opiate use 30% tested out blockade blood levels at 4-5 weeks were 3-5ng/ml this level blocks 500mg diamorphine “troublesome tissue reactions infrequent”

Cont... NTX implant as maintenance treatment (Carreno et al 2003) 156 patients on maintenance antagonist using implant for 1 year with 1 year follow up retention 80% at 6 months, 65% at 12 months at 18 months 55.4% in contact ALL opiate free (20.8% at 24 months)

UK Evidence: Stapleford study 150 consecutive patients 6 week naltrexone implants - two year period, opiate-free:- 100% at 5 weeks 80% at 3 months 60% at 6 months Re-implantation:-41% second implant 18% third implant 13% fourth implant 5% fifth implant (Brewer, 1999).

Potential problems with implants Psychological “wonder cure” coping with being drug free taking away freedom of choice Physical implant site - reactions trying to over-ride implant

Taking implants forward in the UK As unlicenced only appropriate in a research setting Several trials being proposed – but problems with indemnity… WATCH THIS SPACE….