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Drug Misuse: Opioid Detoxification

Drug Misuse: Opioid Detoxification

NICE Clinical Guidelines - National Collaborating Centre for Mental Health (UK)

Version: 2008

ASSESSMENT AND TESTING

Testing and assessment are important aspects in the management of detoxification. Clinical assessment is important in deciding if detoxification is appropriate for the service user (that is, if he or she is opioid dependent) and, if so, how most effectively to manage the detoxification. Assessment is also important during detoxification, including the careful monitoring of the service user’s progress and the level of his or her withdrawal symptoms.

INTRODUCTION TO DRUG MISUSE

This guideline is concerned with detoxification from opioid dependence. Of the estimated 4 million people in the UK who use illicit drugs each year (cannabis being by far the most commonly used), approximately 50,000 people misuse opioids, although this may be an underestimate (Roe & Man, 2006). Opioid misuse is also associated with much greater rates of harm than misuse of either cannabis or cocaine. Over 150,000 people are in treatment for opioid misuse and are prescribed opioids such as methadone and buprenorphine (NTA, 2005a; Hay et al., 2006).

PHARMACOLOGICAL AND PHYSICAL INTERVENTIONS IN OPIOID DETOXIFICATION

The aim of detoxification for a dependent opioid user is to eliminate the effects of opioid drugs in a safe and effective manner (WHO, 2006). Appropriate administration of pharmacological agents plays a crucial role in increasing the likelihood of a successful detoxification, while minimising the discomfort of withdrawal experienced by the service user.

EXECUTIVE SUMMARY

The following recommendations have been identified as recommendations for implementation.

SETTINGS FOR OPIOID DETOXIFICATION

Detoxification from opioids takes place in a variety of settings, including the community, inpatient units, residential units and prisons. Although there are no precise data, it has been estimated that if those taking place in prison are excluded, at least 90% of opioid detoxifications take place in the community, with only a very small number being treated as inpatients. The NDTMS (2003–2004) reports that 3% of all drug service users receive inpatient or residential detoxification, but there is no specific data on community-based detoxification or what proportion were opioid cases (NTA, 2005a). In addition, approximately 56,000 service users currently undergo detoxification in prison every year (). In the past few years, there has been an increasing emphasis on legally sanctioned treatment, which may include detoxification, both under coerced conditions as Drug Rehabilitation Requirements (formerly DTTOs) and under voluntary conditions as the Drug Interventions Programme (DIP).

PSYCHOSOCIAL INTERVENTIONS IN OPIOID DETOXIFICATION

Although detoxification from opioids in NHS settings is generally focussed on pharmacological withdrawal, many detoxification programmes, particularly in specialist units, also include an adjunctive psychosocial component (Day et al., 2005). Recent consensus guidance in the UK (Specialist Clinical Addiction Network [SCAN], 2006) and in the USA (Center for Substance Abuse Treatment [CSAT], 2006) suggests that attempts to treat opioid dependence by means of pharmacological detoxification alone have been shown to have high rates of relapse to dependent use. An obvious consequence of a ‘failed’ detoxification treatment is the possibility of engendering pessimism in treatment staff and service users alike. The consequence for some service users, particularly those more vulnerable to expectations of failure, might be a further lowering in self-efficacy and the strengthening of beliefs about the inevitability of continued drug dependence. If treatment outcomes can be enhanced through the quality of the therapeutic environment, the availability of adjunctive psychosocial interventions and consequently improved interactions with staff, this pessimism can be effectively challenged.

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