Opioid withdrawal

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An opioid withdrawal (also: deprivation ; detoxification : English. Withdrawal , detoxification ) is the abrupt or gradual discontinuation of opioids and opiates , as the Cold withdrawal is done alone and without medical assistance or medical assistance in outpatient or inpatient care. Detoxification can be described as successful when the stressful withdrawal symptoms have completely or largely subsided and opioids can no longer be detected in the urine . According to this definition, whether or when a relapse occurs is of secondary importance. Withdrawal from opioids alone without further measures is not a therapy for opioid dependence .

Relapse after inpatient withdrawal is associated with an increased risk of a fatal overdose (due to the now lowered opioid tolerance ). The withdrawal is therefore intended to stabilize a prolonged period of psychosocial care to follow in order to avoid a relapse or delay or the unwanted consequences of recent drug use in terms of harm reduction ( harm minimization to limit). The fact that addicts substituted with methadone had a higher rate of successful withdrawal compared with those substituted with dihydrocodeine (or codeine ) and heroin addicts without substitution is explained as an independent success parameter with the previous structured support in the methadone program.

Indications

According to the treatment guidelines of the medical societies, acute addiction treatment is indicated for dependent illegal opiate consumption. If there is currently no motivation for this form of treatment, other damage-limiting measures are to be offered.

Methods

In addition to cold withdrawal on the patient's own initiative, there are various "qualified" methods of detoxification:

  • drug-free withdrawal (also known as "cold withdrawal"),
  • drug-assisted detoxification,
  • opioid-assisted detoxification ("warm withdrawal"),
  • the forced detoxification (under heavy sedation or under anesthesia ).

Drug Assisted Detox

As symptomatic treatment, a benzodiazepine such as diazepam against anxiety, restlessness and substance craving, an agent to induce sleep such as zopiclone or zolpidem , an antispasmodic agent on the smooth muscles (usually butylscopolamine bromide ) against abdominal cramps and loperamide against diarrhea for a defined time in defined quantities used, whereby the mode of action of the individual drugs and the procedure should be discussed with the patient.

α 2 sympathomimetics also alleviate the symptoms of opioid withdrawal , with lofexidine (trade name: Lucemyra ; manufacturer: USWorldMeds ; previously only approved in the USA) having a lower blood pressure-lowering effect than clonidine . Clonidine and lofexidine act on the noradrenergic system and some withdrawal symptoms are caused by its overactivation. In particular, these are a runny nose and eyes, sweating, chills and goose bumps as well as diarrhea.

Opioid Assisted Detox

In the United States and Great Britain, methadone is primarily used for opioid withdrawal. A 21-day inpatient detoxification with methadone leads to a prolonged withdrawal syndrome, which, regardless of the dose taken, only subsided about six weeks after the start of the detoxification. A ten day inpatient detox shows similar results. Patients with increased fear of expectation and neurotization at the start of treatment have more severe withdrawal symptoms, while patients with good information about the expected course have milder withdrawal symptoms. Withdrawal with buprenorphine is likely to lead to milder withdrawal symptoms and is especially indicated if naltrexone is subsequently prescribed to prevent a relapse. Dihydrocodeine can be used in patients with a short history and low heroin use.

Termination of a substitution program

Vincent P. Dole , as one of the founders of the methadone-supported substitution program , went so far as to claim that any withdrawal from methadone (for long-term addicts in the substitution program) was an experiment with the patient's life, and by this meant that a substitution program could be continued for so long should be as the patient wishes. Imposing immediate termination of substitution treatment (for a wide variety of reasons) corresponds to “cold” withdrawal; this "is physically and psychologically very stressful, harbors high risks and hazards and is obsolete, since the risk of relapse and the life-threatening overdose risk due to a reduced opioid tolerance is very high." Since it is obsolete , this approach can also be viewed as a treatment error. Thus, the end of treatment should be gradual and in agreement with the patient.

Effectiveness of opiate withdrawal treatment

While a success rate (in the sense of achieving an opiate-free state) in the range of 24% was estimated for an independent withdrawal from heroin, this rate for inpatient treatment is on average two to three times as much. It is also believed that the success rate of a cold withdrawal is much lower compared to a warm withdrawal.

However, complete opiate withdrawal alone is usually not considered sufficient to achieve sustained abstinence. If opiate withdrawal is not followed by “post-acute treatment” (such as long-term inpatient therapy or outpatient treatment using the opiate antagonist naltrexone ), there is a considerable risk that opiate use will resume soon.

history

The question of how and how quickly withdrawal from opioids, at that time still from morphine , should be carried out, was discussed in a similarly contradictory manner as early as the 19th century.

According to Scheffczyk (quoted in Steinat's dissertation), Levinstein's "sudden withdrawal" was introduced in 1875, the gradual withdrawal of Burkart since 1877, and the so-called "rapid withdrawal" explained by Adolph Erlenmeyer in his 1887 monograph. Erlenmeyer describes gradual weaning as the oldest of the various withdrawal methods, which consists in “reducing the dose of morphine to be administered by a small amount every day. This diminution is usually based on the symptoms of abstinence presented by the patient. The more unpleasant and more pronounced these are, the smaller the reduction and the longer the whole cure lasts. The patient is not monitored, but can arrange his external life at will. ”Erlenmeyer does not hesitate“ for a moment with the admission that a large part ”of his morphine addicted patients have betrayed him under this treatment. In addition, however, he also mentions the prolongation of abstinence phenomena as a further considerable disadvantage: "Because of the long duration, the patient is maltreated in the most sad way, and his strength is considerably consumed."

According to Erlenmeyer, the sudden withdrawal according to Levinstein can be carried out in four to six days, whereby a certain education of the staff is absolutely necessary “because this gives the excited sick a significant support and a great support and prevents them from leaving themselves immeasurably allow."

Erlenmeyer himself changes this withdrawal method by individualizing it and taking into account the extent and duration of the morphine consumption, the number of previous withdrawal treatments and the patient's state of strength. As a rule, he first immediately withdraws half of the previously administered dose and then repeats this reduction by half once or twice during the treatment. The first halving of the dose is usually tolerated well because the “working dose” that most morphinists need in order to be able to work is often exceeded by them, what he calls the “luxury dose”. With this method without rigid rules, he withdraws in six to twelve days. The more pronounced symptoms compared to the gradual withdrawal would be more than compensated for by the much shorter duration and the treatment would be appreciated accordingly by the patients.

In the Bellevue sanatorium , at the end of the 19th century , morphinists were withdrawn partly with cocaine in the sense of a drug-assisted detoxification at the time, and partly gradually with morphine itself.

Ernst Speer , who resolutely opposed the (due to the monstrous shock) "educationally extraordinarily effective" cold withdrawal in a closed ward and described it as unnecessary and cruel, in 1919, on behalf of his boss at the time, Hans Berger, set the withdrawal in twilight sleep with Luminal and Scopolamine on an open compartment. This withdrawal, however, had to be followed by psychotherapy . Speer stayed with this method until 1936 and claimed a success rate of one hundred percent - success here again: completed inpatient detoxification. Speer also recognized that withdrawal alone was pointless. His withdrawal program therefore included psychotherapeutic follow-up treatment to ensure success, which was very important. However, this treatment was only promising in neurotics . The "unstable" and thus degenerate had no prospect of healing and were seen as "ineducible". In 1949, Speer described the gradual withdrawal of earlier times as a malpractice and gross mischief. In 1961, however, he said: There are “no real cures from addiction. What looks like this from time to time is usually not permanent. "

Individual evidence

  1. ↑ Eric C. Strain, Maxine L. Stitzer:. The Treatment of Opioid Dependence . 2nd Edition. The Johns Hopkins Univ. Press, Baltimore 2006
  2. ↑ R. Pfab, Chr. Hirtl et al .: The antagonist-induced-anesthesia-assisted opiate rapid withdrawal (AINOS) risky and advantages not proven. ( Memento of the original from November 30, 2010 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF) In: Münchner Medizinische Wochenschrift , 1996/11/22 @1@ 2Template: Webachiv / IABot / www.toxinfo.org
  3. ^ R. Saitz, MJ Larson, C. Labelle, J. Richardson, JH Samet: The case for chronic disease management for addiction. In: Journal of addiction medicine. Volume 2, number 2, June 2008, pp. 55-65, doi : 10.1097 / ADM.0b013e318166af74 , PMID 19809579 , PMC 2756688 (free full text).
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  5. ↑ J. Strang, J. McCambridge, D. Best, T. Beswick, J. Bearn, S. Rees, M. Gossop: Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. In: BMJ (Clinical research ed.). Volume 326, number 7396, May 2003, pp. 959-960, doi : 10.1136 / bmj.326.7396.959 , PMID 12727768 , PMC 153851 (free full text).
  6. ↑ a b M Backmund, K Meyer, D Eichenlaub, CG Schütz: Predictors for completing an inpatient detoxification program among intravenous heroin users, methadone substituted and codeine substituted patients. In: Drug Alcohol Depend. , 2001 Oct 1, 64 (2), pp. 173-180, PMID 11543987 .
  7. ↑ a b AWMF online - Addiction guideline: Acute treatment of opioid-related disorders , guidelines from Dt. Ges. F. Addiction research and addiction therapy (DG-Sucht) and the Dt. Ges. F. Psychiatry, Psychotherapy and Neurology (DGPPN), version of December 18, 2006.
  8. ^ Mathias Berger (Ed.): Mental illnesses - clinic and therapy . 3rd edition Elsevier, 2009.
  9. ↑ Nicholas Seivewright, assisted by Mark Parry: Community Treatment of Drug Misuse: More Than Methadone. Cambridge University Press, 2009.
  10. ↑ FDA approves the first non-opioid treatment for management of opioid withdrawal symptoms in adults , PM FDA dated May 16, 2018; accessed on May 29, 2018
  11. ↑ L. Gowing, M. Farrell, R. Ali, J. White: Alpha-2 adrenergic agonists for opiate withdrawal . Cochrane Database Syst Rev. 2004 Oct 18; (4): CD002024.
  12. ↑ G. Gerra, A. Zaimovic, F. Giusti, C. Di Gennaro, U. Zambelli, S. Gardini, R. Delsignore: Lofexidine versus clonidine in rapid opiate detoxification . In: J Subst Abuse Treat. , 2001 Jul, 21 (1), pp. 11-17, PMID 11516922 .
  13. ↑ M. Gossop, B. Bradley, GT Phillips: An investigation of withdrawal symptoms shown by opiate addicts during and subsequent to a 21-day in-patient methadone detoxification procedure. In: Addict Behav. , 1987, 12 (1), pp. 1-6, PMID 3565107 .
  14. ↑ GT. Phillips, M Gossop, B Bradley: The influence of psychological factors on the opiate withdrawal syndrome . In: The British Journal of Psychiatry , 1986, 149, pp. 235-238, PMID 3779283 .
  15. ↑ L. Green, M. Gossop: Effects of information on the opiate withdrawal syndrome . In: Br J Addict. , 1988 Mar, 83 (3), pp. 305-309. doi : 10.1111 / j.1360-0443.1988.tb00472.x
  16. ↑ Vincent P. Dole: Detoxification of Methadone Patients, and Public Policy . In: JAMA , 1973, 226 (7), pp. 780-781. quoted from: Nicholas Seivewright, assisted by Mark Parry: Community Treatment of Drug Misuse: More Than Methadone . Cambridge University Press, 2009
  17. ↑ Exit scenarios ( Memento of the original from May 25, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Austrian Society for Drug-Based Treatment of Addiction Disease (ÖGABS) @1@ 2Template: Webachiv / IABot / www.oegabs.at
  18. ^ Mattick RP, Hall W .: Are detoxification programs effective ?. The Lancet 1996; 347 (8994): 97-100.
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  20. ↑ Havemann-Reinecke u. a .: AWMF guidelines: Post-acute treatment for disorders caused by opioids , SUCHT magazine, volume 40, pp. 226–257
  21. ↑ a b Stefan Frank Scheffczyk: Cocaine therapy for morphine addiction using the example of the “Bellevue” sanatorium in Kreuzlingen (1884–1887) . Med. Diss. Tübingen 1997
  22. ↑ a b Jens Alexander Steinat: Ernst Speer (1889-1964), Life - Work - effect . (PDF; 2.3 MB) Dissertation at the Medical Faculty of the Eberhard Karls University in Tübingen, 2004
  23. ^ JA Albrecht Erlenmeyer: The morphine addiction and its treatment 1887. The methods of withdrawal p. 113ff; Eliborn Classics
  24. ↑ p. 116
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