This section deals with the practical issues around prescribing and the rate of detox, the anxieties for clients about detox and the alternatives to methadone in detox.
This section should be read in conjunction with:
People reducing from methadone are often anxious and afraid of the withdrawal syndrome and relapse.
Relapse following detox is an often neglected area because drug services and drug users tend to concentrate on the withdrawal syndrome and process of detoxification.
Effective follow up is vital in ensuring that detoxification is more than a reducing dose of methadone mirrored by a concurrent rise in heroin (or other depressant drug) use or a prelude to a short period of abstinence followed by relapse that the prescriber is unaware of.
Information for clients on the issues around detoxification and residential rehabilitation is available in the Detox Handbook and the Rehab Handbook - also available from ISDD (address on back cover).
Reasons for detoxing
These are discussed below.
Attitudes of staff
This can probably be best avoided by offering services that are:
Following these principles also means that, having discussed the options, if a client decides to detoxify against advice the staff should still offer their full support and encouragement during and after the detox. They should also endeavour to discuss possible outcomes in a way that does not set the client up to fail but allows the making of contingency plans that can be brought into play if the detox does not work.
Unrealistic staff beliefs about a client's ability to detox
Cushman and Dole87 found that of a group of methadone maintenance clients who were assessed as 'rehabilitated' and detoxed with the anticipation of success, some asked to be returned to maintenance during the detox and 25% returned to maintenance after detox (mainly because of protracted withdrawals).
Therefore support, encouragement and optimism should always be tempered by continual reassessment and meaningful negotiation.
Unrealistic client beliefs about their ability to detox
This belief sometimes stems from concentrating on the physical aspects of opiate withdrawal. If past experience of relapse during or after opiate detox has been that the withdrawal symptoms were the main factor causing relapse, this can reinforce the belief that if the physical symptoms of withdrawal can be reduced to tolerable levels by a methadone detox, abstinence will be easily achieved.
Another factor can be the flawed but understandable and apparently logical conclusion that 'if all my problems are heroin-related then if I give up heroin all my problems will go away'. The experience of many is that the compulsive behavioural aspects of their drug taking and the social and emotional difficulties that they experience once opiate-free add a previously ignored and difficult-to-overcome dimension to their drug use.
Stigma associated with having a methadone prescription
For the relatives and friends of people on methadone it can be perceived as being 'as bad as heroin' - regardless of any associated lifestyle improvements that have been achieved. Indeed associated improvements often serve only to increase the pressure on the person to detox as the perception is that they do not need the methadone anymore.
Heroin users are often dismissive of those on methadone and street myths of the terrible long-term health consequences of methadone treatment still abound. So the person receiving methadone often feels stigmatised from all sides.
Heroin users who feel the need to seek help for the first time also feel this and may request a methadone detox so that they can rationalise their request as one for a short-lived intervention that does not involve long-term methadone treatment.
Dislike of practical aspects of a regime, such as the collection frequency
It is important for the worker involved to have an awareness of these issues if they are factors in a request for methadone detoxification.
Change of drug of choice
They may ask for a detox at the end of the opiate part of the cycle - either as a new referral as a heroin user or following a period on methadone. In these cases treatment may or may not be appropriate, but if commenced should be carefully monitored.
Clients going to prison
Blind or open reductions?
The answer for most people who attend prescribing and dispensing services that are flexible enough to offer both, is to consider the pros and cons of each approach in conjunction with the prescribing staff, and to make an informed decision for themselves as to which is the most appropriate regime. Generally a key factor is the level of control that a person feels they have over their lives. Anyone who feels in control is unlikely to opt for blind dose reductions.
The arguments for and against blind and open reductions are set out below.
Setting the appropriate rate of detox
For people detoxing following a period on methadone maintenance, faster detoxes are associated with higher drop-out rates and slower detoxes are associated with lower drop-out rates.89
In general detoxes consist of gradual reductions of 5mg or 10mg in the daily dose to a given level, usually 20-30mg (depending on the starting dose and the client), and then become more gradual, either in terms of time between reductions and/or size of daily dose reduction.
Negotiation between worker and client is an important component of any detoxification. A negotiated detoxification in which the client is able to take responsibility for coping with the dose reductions is likely to reduce the risk of concurrent illicit opiate use and be a better foundation for continued abstinence afterwards.
Prescribers without specialist experience who agree to a short-term programme without support from a specialist service should seek support if their patient is unable to detox successfully at the agreed rate.
Detox regime suggestions
Long-term detox regimes are seldom the optimum treatment option, to read an additional piece on long-term detox written for this online edition of the book, please click here.
All the regimes below are for methadone mixture 1mg/1mL. All detox regimes are a plan only and should be subject to regular, i.e. weekly or fortnightly, review against the treatment aims.
The definitions, indications and contra-indications for each of the regimes below are given in Section 7 - Treatment aims and choices. It is important that detox regimes are only entered into with clear treatment aims and following a thorough assessment that has established that these aims are achievable.
The very low doses (i.e. less than 5mg) suggested in the following regimes are of little physiological value as they are unlikely to make much difference to the level of physical withdrawal. However withdrawal symptoms can also be aggravated by anxiety and where low dose prescribing at the end of a detox reduces anxiety it is likely to reduce subjectively experienced withdrawals.
Where a client has high levels of anxiety about making the final reductions they are often afraid of being drug free and of the changes this will bring. It is therefore important that low dose prescribing is coupled with counselling.
Short-term detoxification: decreasing doses over one month or less Two week detoxification regime
This regime has the advantage that it is easy to prescribe as there is a dose drop at the end of each week.
An alternative starting slightly higher could be:
For people who need more methadone to stabilise or who are detoxing from an existing methadone prescription there are two main choices. Either reduce the dose prior to the final detox or reduce the dose by 25%-50% each day until 20mg is reached and then complete the programme as above. However it must be recognised that these large early reductions will probably result in intense withdrawal symptoms.
If required, 'holding' on a given dose on one or two occasions during the detox may increase the client's sense of control and decrease their anxiety. Delays in the rate of reduction should usually be accompanied by an increase in psychological support.
Longer-term detoxification: decreasing doses over 1-6 months
1 month detoxification regime
From a starting dose of 40mg:
From a starting dose of 25mg:
4 month detoxification regime
The rate of reduction in the daily dose is then reduced to 5mg every week or fortnight until 10-15mg is reached. At this point daily dose reductions can be reduced to 2 or 2.5mg every week or fortnight.
A typical 4 month regime using these principles from a starting dose of 45mg would be:
6 month detoxification regime
Detoxification following exclusion from a methadone prescribing programme
The client should be aware of exactly what the rate of detox will be before the prescription is terminated. Abrupt cessation of opiates is not fatal in people who are otherwise healthy. The rate of reduction therefore usually seeks to strike a balance between continuance of the prescribing programme under a new guise, and a rate of reduction which gives the individual little chance of achieving abstinence if they want to.
A regime such as the following is commonly used:
However any of the above regimes could be employed.
As with all anxiety-provoking situations, levels of anxiety during and after methadone detoxification can be reduced through information being given to the client about what they can expect to happen and why it is happening, and the opportunity being given to discuss the issues that are raised.
Emotions such as anger and depression can trigger withdrawal symptoms in people who are stabilised on methadone - this is known as 'pseudo withdrawal syndrome'. If clients become more aware of these feelings during a detox then this too will increase the severity of their withdrawal symptoms. Counselling during and after the detox can help deal with these emotions and reduce the physical consequences.
Indeed many clients become very anxious as soon as dose reductions begin and feel unable to continue with the detoxification. Hall suggested that previous actual or observed traumatic experience of withdrawal symptoms may be the cause of this fear. Unfortunately her attempts to use standard cognitive behavioural therapy in a controlled trial - which has been shown to be effective in other anxiety disorders - were unsuccessful.
This being the case, choices for clients who demonstrate high levels of anxiety during detox are limited as they are unlikely to achieve abstinence without considerable support. Slowing the rate of reduction and increasing support is the first line response. Following this in-patient detoxification or residential rehabilitation might be options.
If the anxiety cannot be resolved, and relapse is the outcome of all attempts at detox, the most appropriate response may be methadone maintenance.
Alternatives to methadone in detoxification
It works by inhibiting the release of noradrenaline. Noradrenaline is a key chemical transmitter that acts on the nervous system, the action of which has been suppressed by opiates: see Section 4: The physiology and pharmacology of methadone.
As lofexidine is not an opiate, increasing the dose too quickly, or beyond the recommended maximum, will not necessarily reduce withdrawal symptoms but it will increase the risk of side effects such as hypotension (low blood pressure). This should be made very clear to patients who are self administering their lofexidine tablets.
The safety of lofexidine in pregnancy has not yet been established.
Lofexidine is unlikely to:
The effect of these factors can be reduced by:
Blood pressure should be monitored, especially while the dose is increasing. For in-patients if the standing systolic BP has dropped by more than 30 mmHg (and is associated with symptoms of dizziness and light-headedness or over-sedation) the next dose of lofexidine should be withheld until the systolic BP is less than 30mmHg below the baseline.
Sedation is more likely to occur in clients concurrently prescribed (or taking) benzodiazepines and/or other central nervous system depressants.
Lofexidine is safe for community use in patients who are:
A typical 10 day out-patient lofexidine regime
The following morning (detox day 1) begin the following regime:
The patient must be told:
The rationale for this is that dihydrocodeine is:
There have been no controlled trials comparing subjective experience of withdrawals when detoxing on methadone, heroin or dihydrocodeine, but some clinicians have found the switch helpful, particularly if the anxiety of withdrawal is focused on the problems of coming off methadone.
However the treatment can have drawbacks. The experience of a 'high' on dihydrocodeine can be greater than with methadone and thus clients can attempt unsustainable methadone dose reductions in pursuit of the 'reward' of a 'better drug'.
Switching drug can also detract from the other psychological causes of withdrawal symptoms, neglect of which is unlikely to be therapeutic.
The product licence for dihydrocodeine does not include treatment of opiate dependence.
Methadone v heroin in detoxification
Given that methadone is a longer-acting drug this is probably true. However the experience of withdrawal is probably exacerbated by factors which are different with regard to most methadone detoxes as opposed to most illicit heroin detoxes.
Most illicit heroin withdrawal symptoms are:
Most methadone withdrawal symptoms are:
These factors probably all increase the stress associated with methadone dose reductions and serve to increase the subjective experience of withdrawal symptoms. Discussion of these issues with the client will probably serve to reduce the severity of the withdrawal experience.
Follow up/relapse prevention
Risk of relapse is always high as there are many potential causes of relapse including:
The person who has succeeded in getting off opiates will need help to resist these cues to relapse. Often clients are reluctant to return to prescribing services for follow-up support and there are often few services for those that do.
Support that would help and could be provided by drug services includes:
Support that could be suggested/facilitated by drug services includes: