In Home Detoxification, the addict simply stops his drug of addiction and then has to get through four or five days of very painful and distressing withdrawal symptoms. Even in a hospital or a special detox unit, there may be great suffering, a high failure rate and some risk of OD if it fails.
In Rapid Detox, substantial intravenous injections of narcan are used to rapidly block or displace all residual heroin in your body, whilst clonidine and four or more other Withdrawal Management Medications, are injected intravenously to minimize the withdrawal symptoms. The withdrawal symptoms are severe, because there is such a rapid reduction in the heroin levels, due to the substantial intravenous narcan injections; especially if you haven't stopped or substantially reduced your heroin intake in the previous three days. This means that high doses of Withdrawal Management Medications intravenously are needed; (clonidine, sedatives, vomiting, diarrhoea, cramp and painkilling medications).
The Rapid Withdrawal, together with all the Withdrawal Management Medications injected straight into the blood stream, may make you very uncomfortable and quite disturbed and dependant on others to care for you for a few hours or days. Dehydration and the need for a drip or hospitalization is possible.
There are advantages with a new alternative, Incremental (Stepped) Rapid Detoxification, in which small doses of Narcan (Naloxone) subcutaneously and naltrexone orally, are given every hour or so, together with reduced Withdrawal Management Medications, mostly orally, as necessary. These smaller, more tolerable bites of Rapid Detox every hour or so, given by the slower oral and subcutaneous routes, get rid of the heroin more quickly and surely than simple Home Detoxification, but more slowly, a bit at a time, than with intravenous Rapid Detoxification. If the steps turn out to have been too fast and excessive withdrawal symptoms develop, the situation can be controlled quickly by sucking Buprenorphine tablets. There is less need for Withdrawal Management Medications, staff and facilities. There is less drama, trauma and cost, than with Rapid Detox. The patient is alert and in direct consultation with his doctor, with ongoing assessment, problem solving and support until the situation has been resolved. It is possible to be detoxed and stabilized on Naltrexone Maintenance Therapy with 2 to 4 small manageable bites. However it does involve attending the clinic for 2 to 3 hours on 2 or 3 successive days.
The Best Detox Option is S.P.E.E.Q.E. (Safe, Painless, Easy, Effective, Quick, and Economical) Detoxification. All narcotics are reduced or stopped and repeated small doses of Buprenorphine are sucked under the tongue as necessary, as soon as the patient starts to feel withdrawal symptoms. Three days after the last heroin, 5 days after the last morphine or 21 days after the last methadone, very small test doses of narcan may be given subcutaneously. Very small test doses of naltrexone are given after each dose of narcan. If a withdrawal reaction occurs, the narcan and naltrexone are stopped, as this reaction means the patient is not yet clean. More Buprenorphine tablets are then sucked and additional time is allowed, so that the narcotics of addiction can be further broken down and excreted by natural body processes. The narcan and naltrexone are then recommenced, proceeding more slowly than before. At Western Australian prices the amount of Buprenorphine needed each day will cost approximately 10% as much as the heroin has been costing. That is, someone spending $100 per day on heroin will need to spend about $10 per day on Buprenorphine. (From August 2001 the Australian Government has subsidised Buprenorphine, reducing the cost to a maximum of $A4 per day, regardless of the daily amount needed.This makes it better for most people to continue on with the buprenorphine for a few weeks or months until all the Pre-existing, Underlying Factors have been discovered and corrected; in this case narcan and naltrexone are no longer needed - I very seldom use them now.)
A great breakthrough has recently occurred for heroin addicts in Western Australia. Buprenorphine has become available again for narcotic detoxification, and as a maintenance therapy alternative to Methadone. Addicts enthusiastically describe it as being far better than any other method of getting clean that they have tried. They are amazed at how quickly, easily and painlessly it gets them off heroin, morphine and oxycontin. Buprenorphine has been available for treating pain for twenty years in this country. Its use in treating addiction was stopped by Health Authorities in 1983 for no good reason. It has been available for treating narcotic addiction in France for 6 or 7 years, where its use has been very successful. Its use in treating narcotic addiction is now rapidly spreading throughout the world and this has forced our WA Health Department to admit their mistake and release it again for the treatment of addiction.
Buprenorphine is a man made narcotic and is the least addictive mid strength narcotic there is. It is also a powerful antagonist (blocker) of the opioid nerve receptors. This means that it provides both moderate narcotic effect and relief, and also strongly blocks craving for and the effects of, other narcotics. Patients can be weaned off it without any difficulty or suffering, unlike methadone which is horrendously difficult and painful to get off. Methadone is what our "experts" chose 20 years ago when they rejected buprenorphine.
The step from narcotic addiction to being clean, which has been so distressing, difficult and potentially dangerous, can now be painless, quick, easy, cheap and quite safe.
The heroin is simply stopped and as soon as hanging out begins, it is promptly relieved by sucking as much buprenorphine under the tongue as is necessary, starting with 1 to 2 mgms every hour. After three or four days, all the heroin has been broken down and excreted and the addict is clean. I usually then keep patients on buprenorphine in reducing doses, until all the Pre-existing Underlying Factors, which always underlie every addiction, have been discovered and corrected. Then it is no problem to gradually wean off the buprenorphine and relapse is much less likely to occur.
In a small number of people with serious and entrenched Underlying Problems, buprenorphine may have to be continued for a longer period as maintenance therapy until these Underlying Problems have been resolved. It is vastly superior to methadone, heroin and morphine as maintenance therapy in these circumstances, probably making the idea of trialing or legalizing heroin as maintenance therapy, unnecessary.
Side effects seldom occur with buprenorphine and are almost always comparatively mild. They include drowsiness, headaches, disturbed sleep, sweating, nausea and vomiting. Respiratory depression and overdosing are very rare unless buprenorphine is taken with large amounts of alcohol or benzo's, which should be avoided whilst on buprenorphine. Care should be taken with driving or operating machinery but these activities are not usually a problem on buprenorphine.
Western Australian Health Department policy means that if a doctor becomes aware that a buprenorphine patient has become pregnant, then that doctor must wean that patient off buprenorphine as soon as possible. Effective contraception is therefore very advisable for females on buprenorphine. The Health Department, in its wisdom, recommends that patients becoming pregnant be transferred to methadone, which I believe is a terrible mistake.
If a patient has used a lot of speed in the past, buprenorphine is still the best treatment for any narcotic addiction they have. However on its own it may not fully satisfy and settle them. In this case they may also need to take 2 to 10 dexamphetamine tablets per day. One to four tablets should be taken when they first wake in the morning. Another one to three tablets may be needed four hours later. Sometimes a further one or two tablets are needed a few hours later, but shouldn't be taken less than eight hours before the anticipated bedtime. Sometimes Ritalin works better than dexamphetamine but in Australia it is more expensive. When a patient goes onto dexamphetamine, their buprenorphine dose can usually be considerably reduced.
GETTING OFF HEROIN; STAYING OFF HEROIN; DISCOVERING AND CORRECTING THE UNDERLYING FACTORS THAT LED TO THE ADDICTION, OR KEPT IT GOING.
1. GETTING THE WHOLE PICTURE
Understanding the Whole Person, their Background, their Present Circumstances and their Desires and Goals and their Unusual/ Disturbed/ Distressed Chemistry, using A Systematic Comprehensive Chemical Health Record.
2. DETOXIFICATION using
S afe Buprenorphine
P ainless Withdrawal
E asy Management Medications
E ffective and
E conomical Group and Personal Support
3. MAINTENANCE THERAPY using only as necessary
Naltrexone or Buprenorphine
Serotonin Boosters (SSRI's)
Mood Stabilisers (Usually Epilim) only as necessary
Stimulant Therapy (Dexamphetamine or Ritalin)
Personal and Group Support
4. UNDERLYING FACTOR DISCOVERY & CORRECTION
Discovery / Correction of the Pre-existing Underlying Factors that led to the addiction
and kept it going, using
The Systematic Comprehensive Chemical Health Record
Individual, Couples and Family Counselling
Psychiatric and Psychological Assessment and Treatment where necessary
Long Term Specialised Groups and Other Treatments as Appropriate
(i) Get the patient to state and repeat several times, whether or not they truly wish to get off and stay off Narcotics and leave the drug world. Listen carefully to the voice volumes and tones and observe carefully the facial expressions. Try to determine their real desires and intentions from this body language. Get them to reinforce their intention by repeating it several times in a louder and louder voice.
(ii) If you feel reasonably confident that they do wish to get off and to stay off Narcotics, then ask them to stop their Narcotics and immediately give them one mgm of Buprenorphine to suck under the tongue. Give another 2mgms to be sucked, when withdrawal symptoms recur. (See special notes below on withdrawal from Methadone under item (xi) as withdrawal from Methadone is more complicated and slower). If given too large a starting dose vomiting, precipitated withdrawal and respiratory distress may occasionally occur. Buprenorphine is strong medicine and the first few doses of a strong medicine should nearly always be small to detect sensitivities or side effects, even though these are uncommon with Buprenorphine.
If you have serious doubts about the clarity or certainty of their desire to give up Narcotics, discuss the need for clarity of desire and determination if they are to succeed. Even if motivation is in doubt, it is usually best to proceed, as an abortive first attempt is likely to promote success later on.
(iii) Ask the patient to take no more Narcotics till you see them again and supply them with a further 2 to 8 mgms to suck that evening and supply them with Withdrawal Management Medications as you think necessary (Clonidine 50- 75mgms 4 hourly, Maxalon, Imodium, Vioxx or Surgam, Sleepers, Tranquillizers, Quinine Bisulphate and Buscopan. Withdrawal Management Medications are seldom needed with this technique).
(iv) The patient should then go home and be cared for by a friend, relative or volunteer and come back for review the next day.
(v) At review the next day, check for vomiting, headaches, excessive drowsiness, dehydration, insomnia, any other withdrawal symptoms and the patient's general condition.Nausea and vomiting should be treated with metaclopramide, promethazine, haloperidel, or zofran wafers. If there are no undue problems (which is usually the case) then an 8mgm tablet can be supplied or prescribed, to be taken over the next 24 hours. It should be sucked in quarters or halves, as needed and tolerated.
If there have been or still are side effects or an unacceptably strong withdrawal reaction, go back to reduced doses of the drug of addiction until everything settles down. Then recommence the Buprenorphine treatment at lower doses and increase steadily, up to a maximum daily dose of 16mgm. Some overlap of the drug of addiction and the buprenorphine may be needed at times. As Buprenorphine has a very long half life and gradually accumulates in the body, the daily intake can sometimes be reduced after a few days.
(vi) The advantage of the smaller 0.2mgm tablets is that the Buprenorphine can more easily be introduced in smaller amounts and increased more gradually, reducing the chances of Precipitated Withdrawal with Methadone, or of the nausea and vomiting a few patients get with a new narcotic. The advantage of the larger 8mgm tablets is that they are one tenth the cost per mgm of the medication. Of course the larger tablets can easily be cut or broken into halves, quarters or eighths and this is often satisfactory. It is usually best to start with 8mgm tablets. Any intolerance which may very occasionally occur can then usually be overcome by switching to the 0.2 mgm strength tablets and then slowly working back up to the 8mgm tablets again. If you give the patient too large a prescription for tablets on the first or second day, they often won't come back for review and fine tuning till they have used them all, run out, think they have beaten their addiction and are back in trouble again. Some authorities insist that each dose be administered directly to the patient by a pharmacist. Whilst there are diversion and other not very strong arguments in favour of this policy, it greatly reduces flexibility and success in treating patients in the first place.
(vii) The patient should be seen very often until they have had no heroin or similar Narcotic for 5 days. At that point, they can continue to suck Buprenorphine as necessary, or they can be given very small doses of Naloxone (Narcan) and Naltrexone (Revia). The needle of a 100 unit insulin syringe containing 120mcg of Narcan in 30 units is pushed into the subcutaneous tissues of the upper outer arm and the syringe is strapped in place firmly with adhesive tape. 10 units of the mixture containing 40mcg of Narcan is then injected subcutaneously. A mixture of 1 crushed Naltrexone tablet in 2 litres of water, cordial or juice (50mgm in 2000mls) is prepared. Five minutes after receiving the Narcan, 40mls of this mixture, well shaken, (1mgm of Naltrexone) is given to the patient to drink. The patient with friend, relative, nurse or volunteer is allowed to rest and watch T.V., have a cup of tea, sit in the fresh air, go for a walk etc.
(viii) If the Naltrexone Option is chosen - and we seldom use it now - after about 45 minutes they are checked for withdrawal symptoms (yawning, sneezing, watering eyes or nose, goose bumps, arm leg or back aches, hot & cold sweats, gut cramps, diarrhea or vomiting). If there is no reaction at all, then they are probably Opiate free and ready for Naltrexone. Give them a further 20 units or 80mcg of Narcan and then 40mls (1 mgm) of Naltrexone mixture 5 minutes later and allow them to go home with the instruction to continue to drink more Naltrexone every 3 hours, but to stop and suck Buprenorphine if they get a significant withdrawal reaction. If there is a withdrawal reaction then they still have opiates in their body. More Buprenorphine should be sucked and Withdrawal Management Medications taken as needed. Further doses of Naltrexone should be withheld until the next day, depending on the strength of the reaction and the level of care available. This reaction means the patient is not yet clean enough to be on Naltrexone. The next day the process can begin again and be stopped and started until there is no reaction to larger doses and 2 litres of Naltrexone mixture (50mgm of naltrexone) has been consumed. The patient can then go onto 1 Naltrexone tablet every morning (or 1/2 or 1/4 or 1 1/2 or 2 tablets as needed and tolerated). There should be a compromise between taking the minimum dose that securely inhibits their craving for narcotics and the maximum dose that does not give them gut or nervous side effects. (Nausea, anorexia, diarrhoea, anxiety/arousal, insomnia).
(ix) The popularity of naltrexone has waned considerably recently, due to side effects, cost, difficulties in achieving regularity of dosing and the worry as to whether there is an increased risk of O.D. in people who have been on naltrexone. If the patient doesn't want to go onto naltrexone, buprenorphine should be continued, perhaps at a reducing dose, until intense investigation and treatment of the Pre-existing Underlying Factors that caused and maintained the addiction, has reduced these Factors to the point where maintenance pharmacotherapy is not needed.
(x) Withdrawal of Methadone, which stays in the body for months and is highly addictive, has to be managed differently from withdrawal of other narcotics. If too much Buprenorphine is taken too quickly, a very uncomfortable Precipitated Withdrawal of the Methadone can occur. The best plan is to reduce the daily Methadone dose by 2 1/2 mgms. One mgm of Buprenorphine is then sucked when hanging out begins. 1mgm of Buprenorphine is repeated daily. After a few days the dose of Methadone is again reduced by 2 1/2 mgms. 1mgm of Buprenorphine continues to be sucked each day when hanging out begins. If the Buprenorphine makes the hanging out worse then a Precipitated Withdrawal is occurring. More Methadone should be given in extreme cases, although Clonidine and Clonazepam and reassurance will usually suffice in milder cases. If there is no sign of precipitated withdrawal then after a few days the Buprenorphine can be increased to 2mgms, then 4mgms daily and the Methadone reduced more rapidly. When the daily intake of Methadone has been reduced to 30mgms it can be stopped completely and 8mgms of Buprenorphine, or more as necessary, be sucked each day.
Buprenorphine can be continued, or Naltrexone can gradually be substituted six weeks after the last dose of Methadone. 40mls of a mixture of one 50mgm tablet crushed and well shaken in 2 litres of water (i.e. 1mgm of Naltrexone) is given every 7 days till it produces no reaction. The frequency of the dose can then be increased and when tolerated daily, the dose of Naltrexone is gradually increased. As the naltrexone is increasingly tolerated, the Buprenorphine can be slowly withdrawn.
Some treatment centers insist that patients get down to 30 to 40 mgm of Methadone before starting Buprenorphine. This means that those in greatest need are often not helped. It is extremely difficult, for most Methadone users on higher doses, to get down to 30 or 40 mgm of methadone. Many fail and drop out if they don't have small doses of Buprenorphine to help them reduce their Methadone to the "jumping off" level. However the Buprenorphine doses must be small and the Methadone addict can't, in the early stages, be given buprenorphine tablets to take home - they will nearly always take more than instructed and get into trouble with Precipitated Withdrawal, if given tablets to be taken home & self administered in the early stages.
(xi) In order to maintain the benefits of detoxification, Maintenance Therapy and Underlying Factor Diagnosis and Correction must be vigorously pursued. Some treatment centres just concentrate on switching people from street Narcotics and Methadone to ongoing Buprenorphine Maintenance Therapy. With Maintenance Therapy and Underlying Factor Correction, we get most of our patients completely clean of narcotics and most stay that way. About 10% are too unstable to maintain a clean state and need to be on longer term Maintenance Buprenorphine. In these cases it is particularly important to exclude ADD and Bipolar Disorder, perhaps with a trial of Dexamphetamine or Lithium, even if the patients don't appear to fit these diagnoses, as a common cause of failed detoxification is failure to recognize underlying ADD or Bipolar Disorder.
With Underlying Factor Diagnosis and Correction, ex addicts are less likely to need to stay on Buprenorphine, Naltrexone or other Maintenance Therapy Pharmaceuticals for long periods of time. The quality of their life is permanently improved and their vulnerability to Substance Abuse is reduced long term. Unfortunately in Western Australia the rules with regard to prescribing and administering Buprenorphine have been changed so often in the last year or two, that there is doubt as to whether the authorities know what they are doing. Buprenorphine was first used for treating heroin addiction in Western Australia in the early 1980's, but then our Health Authorities stopped its use and promoted Methadone instead, from early 1984 onwards. They have been talking about doing trials to determine how Buprenorphine should be used, ever since. In my hands on experience of this extremely beneficial medicine I have not found it to be a difficult or dangerous chemical - certainly not nearly as dangerous as the street drugs or Methadone, which we are using it to displace. The shameful procrastination of the authorities has caused untold suffering and cost for addicts, their families and the community at large.
Current regulations mean that in W.A. we have difficulty administering Buprenorphine efficiently, according to an individual patient's needs and in such a way as to maximize the chances of successful detoxification. There are delays in getting the special permission needed to prescribe it, every dose has to be administered at a pharmacy & approval is not given to allow Methadone and Buprenorphine to the prescribed simultaneously for a patient. This precludes the gradual introduction of very small but increasing doses of buprenorphine, as the methadone is being gradually reduced, which is the surest and least traumatic way of getting methadone addicts off that terrible drug.
A person who needs 8mgms per day of Buprenorphine, but who vomits or has severe headaches if they take it all at once, under pharmacy supervision, as presently required, is not allowed to take part of the tablet under supervision and the rest at home, later in the day, which is how we did it before the second latest change of rules. The patient either has to suffer the headaches and vomiting, or to suffer withdrawals and perhaps failure in their detox attempt, by taking a smaller dose of Buprenorphine than they need.
One patient who was on 115mgm of Methadone daily and had never been able to reduce the dose before, is now down to 30mgm and progressing very well on 4mgms per day of Buprenorphine. He had to start on 1mgm per day of Buprenorphine and then gradually increase the dose, because to begin with, more than 1mgm at once caused a flare up of his asthma. The early doses also need to be kept to 1mgm or less, to avoid Precipitated Methadone Withdrawal in some people. Divided daily doses, are very difficult if all the doses have to be administered by a pharmacist at a pharmacy. The pharmacists naturally charge a fee for administering and doing the paper work for each dose, are usually not open 24 hours a day and the addicts don't have transport or money for multiple doses per day. There should be flexibility to allow the patient to take small quantities home, if several small doses are needed over the 24 hours, rather than taking just one larger dose per day at the clinic or pharmacy.
If a patient comes to the clinic hanging out, having already stopped his narcotics, it is essential that he be started on Buprenorphine immediately. If put off for a few days till a formal appointment can be made and permission to prescribe Buprenorphine is obtained - and this is what usually happen - the patient will usually get hold of illicit drugs, to relieve his acute withdrawal suffering, may commit crime to pay for them, and will often slip back to his old ways and contacts. It may then be months before he comes back again for detox and all sorts of bad things may happen in those months, to him, to his family and to other members of the community.
A few patients on Buprenorphine will want to go back to Methadone because on Methadone, when they can afford it or are offered it, they can have the pleasure of a shot of heroin, whereas with Buprenorphine, because of its blocking effect, heroin won't work.