Opioid Use Disorder __________________________________________________________________________
purpose is to eliminate physical dependence on opioid medica- tions. It can be considered the medically supported transition to a medication-free state or to antagonist therapy. A careful and thorough review of the risks and benefits of detoxifica- tion should be provided and informed consent obtained from patients prior to choosing this option [102; 133]. Studies have shown that most patients with opioid use disorder who undergo medically supervised withdrawal will start using opi- oids again and will not continue in recommended care [135; 136; 137; 138; 139]. Detoxification alone should not be consid- ered a treatment and should only be promoted in the context of a well-planned relapse-prevention program [77; 133; 134]. Discontinuation of opioid use must be implemented slowly and cautiously to avoid a marked abstinence syndrome. Withdrawal symptoms may not begin for days after abrupt discontinuation of methadone or buprenorphine given their longer half-lives. Protracted abstinence, or post-acute withdrawal, may last for several months and is characterized by asthenia, depression, and hypotension. Post-acute withdrawal is more likely to occur with methadone than other opioids [56]. The three primary treatment modalities used for detoxification are opioid agonists, non-opioid medications, and rapid and ultra-rapid opioid detoxification [56]. The most frequently employed method of opioid withdrawal is a slow, supervised detoxification during which an opioid agonist, usually metha- done, is substituted for the abused opioid [80]. Methadone is the most frequently used opioid agonist due to the convenience of its once-a-day dosing [56]. Methadone is highly bound to plasma proteins and accumulates more readily than heroin in all body tissues. Methadone also has a longer half-life, approximately 22 hours, which makes withdrawal more dif- ficult than from heroin. Substitution therapy with methadone has a high initial dropout rate (30% to 90%) and an early relapse rate. Alternative pharmacologic detoxification choices include clonidine (with or without methadone), midazolam, trazodone, or buprenorphine [80]. Naltrexone is used follow- ing medically supervised withdrawal to help prevent relapse to opioid misuse [134]. Many opioid withdrawal symptoms, such as restlessness, rhinorrhea, lacrimation, diaphoresis, myosis, piloerection, and cardiovascular changes, are mediated through increased sympathetic activation, the result of increased neuron activity in the locus coeruleus. Non-opioid agents (such as clonidine), which inhibit hyperactivation of noradrenergic pathways stemming from the locus coeruleus nucleus, have been used to manage acute withdrawal [80; 107]. The first non-opioid treatment approved for the management of opioid withdarawl symptoms is lofexidine [109]. In studies, patients treated with lofexidine reported less severe withdrawal symptoms and were more likely to complete treatment. However, some withdrawal symptoms, including anxiety and myalgias, are resistant to clonidine; benzodiazepines and non- steroidal anti-inflammatory agents may be necessary to treat these symptoms. To mitigate withdrawal symptoms and assist in detoxification, alpha2-agonists, opioid agonist-antagonists,
benzodiazepines, and antidepressants have been used [80]. Following detoxification, patients may feel exhausted and weak. Other complications, such as slight variations in hemodynamic status and gastrointestinal tract symptoms, follow quickly and may take several days to resolve. Muscle cramps and low back pain can be treated with nonsteroidal anti-inflammatory drugs. However, the newer cyclooxygenase-2 (COX-2) inhibitors may be advantageous because they produce fewer gastrointestinal side effects [80]. Insomnia is a frequent aspect of acute and pro- tracted withdrawal, as opioids disrupt the normal sleep-wake cycle and many addicts require narcotics to sleep. Although long-term disruption of the normal sleep-wake cycle cannot be corrected rapidly, melatonin (3 mg), benzodiazepines, or antihistamines can be used with beneficial effects. Hypnosis and relaxation techniques are nonpharmacologic methods that may also be used [80]. Psychosocial treatments offered in addition to pharmacologic detoxification treatments positively impact treatment retention and completion, results at follow- up, and compliance [140; 141]. Ultra-Rapid Opioid Detoxification Ultra-rapid opioid detoxification (UROD) has been developed as a means of avoiding the physical symptoms of withdrawal from opioids through the use of general anesthesia. UROD consists of naltrexone-assisted detoxification under heavy seda- tion or full anesthesia. Chemical sedation has been used since the early 1940s in the management of drug withdrawal. The major breakthrough in the management of opioid withdrawal occurred with the addition of an opioid antagonist during chemical sedation [142]. UROD was introduced in 1990 primarily by private practitioners in a for-profit setting [143]. Traditional withdrawal management utilizes the substitu- tion of the short-acting opioid with a long-acting opioid and subsequent tapering or use of non-opioids. This may involve substantial discomfort to patients, who often terminate the detoxification process and return to opioid use. Some may not even attempt to quit due to fears of the discomfort of the with- drawal process. Thus, attempts have been made to induce and shorten opioid withdrawal through the use of UROD [143]. UROD is also referred to as rapid or anesthesia-assisted detoxification. One reason for the proliferation of terms is that the anesthesia-assisted procedure was commercially used and was submitted as a registered trademark or patent. Therefore, other researchers had to devise novel names for the process. Suggested classification is [143]: • Ultra-rapid opioid detoxification (UROD): General anesthesia; duration <6 hours • Rapid opioid detoxification (ROD): Deep sedation; duration 6 to 72 hours • Compressed opioid detoxification (COD) and naltrexone-compressed opioid detox-ification (NCOD): Duration three to six days; preceded by a period of abstinence from opioids under sedation prior to intro- duction of naltrexone
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MDRI2026
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