24-Hour opiate detoxification and antagonist induction at home-the 'Asturian method': a report on 1368 procedures

Size: px
Start display at page:

Download "24-Hour opiate detoxification and antagonist induction at home-the 'Asturian method': a report on 1368 procedures"

Transcription

1 Addiction Biology (2002) 7, RESEARCH ARTICLE 24-Hour opiate detoxification and antagonist induction at home-the 'Asturian method': a report on 1368 procedures J. E. CARREÑO,1 J. BOBES,3 c. BREWER,4 c. E. ALVAREZ,l, G. I. SAN NARCISO,1 M. T. BASCARÁN2 & J. SÁNCHEZ DEL RÍ03 lclínica Médico Psicológica Asturias (CMPA), Gijón, Asturias, 2Psychiatry Department, Faculty o/ Medicine, Ovíedo Uníversity, Asturias, 3Detoxijication Unit, Hospital Central o/ Asturias, Oviedo, Spain and 4The Staple/ord Centre, London, UK Abstract The technique 01 domiciliar y rapid opiate detoxification (ROD) developed in Asturias since 1994 enables patients dependent on heroin and/or methadone (or other opiates) to start antagonist maintenance with a /ull dose 01 naltrexone (50 mg) and largely recover from the acute opiate withdrawal syndrome in a lew hours at home without direct medical or nursing involvement. Detailed inlormation on 1368 procedures is presented but in Asturias, over 3000 procedures have been completed to date without any deaths or serious medical or psychiatric complications. ~ also describe some recent modifications to the procedure involving the use 01 octreotide as an antidiarrhoeal and the insertion 01subcutaneous naltrexone implants to prevent early relapse. Rather than domiciliar y ROD, we think the procedure is more usefully conceptualized as domiciliar y rapid antagonist induction (RAI), because treatment with well-supervised naltrexone is known to be ejjective in reducing relapse rates. Now that controlled studies uniformly describe greatly increased rates 01 transler to naltrexone meaintenance treatment lollowing RAI, compared with conventional slower withdrawal and naltrexone induction procedures, it is important that the salety, acceptability and simplicity 01 this 'Asturian' RAI/ROD technique become more widely known. Introduction Since the mid-1970s, it has been possible to accelerate considerably the process of opiate detoxification and naltrexone induction. Blachly et al. 1 and Resnick et al. 2 were able to transfer patients from methadone to naltrexone in 24 hours using repeated naloxone injections and moderate sedation with benzodiazepines. Using clonidine and light sedation, Charney et al.3 routinely achieved successful naltrexone induction in 4-5 days with an in-patient protocol. Loimer et al. 4 and Brewer et al. 5 were the first to use anaesthesia and generous oral sedation, respectively, to make the process more acceptable and less uncomfortable. Oral naltrexone has been shown in several controlled studies to reduce both early and later relapse after opiate detoxification, provided it is given under supervision.6-8 In this respect, it has some similarities with supervised disulfiram Correspondence to: Dr Colin Brewer, The Stapleford Centre, 25a Eccleston Street, London SWIW 9NP, UK. Tel: ; fax: ; Received for publication 8th March Accepted 20th September ISSN printlissn online/02/ Society for the Study of Addietion to Alcohol and Other Drugs DOI: / Carfax Publishing, Taylor & Francis Ltd

2 244 J. E. Carreño et al. treatment.9,1q Conversely, the immediate relapse rate following conventional detoxification is often at least 50%. It is becoming increasingly apparent that leaving a gap between the process of detoxification and initiating naltrexone provides opportunities for relapse of which many patients unfortunately avail themselves. 11ROD is not only a technique for making opiate withdrawal quicker, less unpleasant and therefore less unattractive; it is also a technique for transferring patients quickly, seamlessly and effectively from regular opiate agonist intake to regular opiate antagonist intake. AlI ROD techniques involve the administration of an opiate antagonist to precipitate acute withdrawal by displacing opiates from opiate receptors throughout the body.12 The resultant withdrawal syndrome is generally more intense but much shorter than that observed after the abrupt discontinuation of opiates and the symptoms can be ameliorated or prevented by various drugs. These include: alpha-2 adrenergic agonists such as clonidine or lofexidine to control the adrenergic hyperactivity, anti-emetics such as metoclopramide or ondansetron, drugs to reduce intestinal peristalsis such as atropinics or octreotide, drugs to reduce gastric secretion and acidity such as H2 or proton pump inhibitors, nonopiate analgesics to control pain during or after the acute phase of withdrawal and sedatives or anaesthetic agents to reduce anxiety, agitation and awareness or to achieve total unconsciousness or amnesia.12 While residual withdrawal symptoms, as Himmelsbach reported in 1942, may persist for several days or even weeks or months,13 there is general agreement that with ROD, the worst is usually over within a few hours. Today so many different ROD protocols have been suggested 14 that the choice of treatment has itself become a problem. In 1997, Carreño et al. 15suggested that for an opiate detoxification technique to be considered as both 'rapid' and acceptable, treatment should last no longer than 24 hours; a complete dos e of antagonist (typically naltrexone 50 mg) should be administered, and adequate control of withdrawal symptoms should be achieved. Despite the obvious advantages of making withdrawal shorter and less unpleasant, there have been concerns about the safety of ROD procedures following a small number of high-profile deaths and exaggerated claims of effectiveness and painlessness.16 Several ROD procedures are currentiy employed in various countries and there is little agreement about the best technique or the indications. Important issues include: whether anaesthesia is preferable to sedation? What sort of sedation? What additional anti-withdrawal medications are needed? Is it better to carry out the treatment as an inpatient or outpatient? The purpose of this paper is to describe one particular protocol; to show that despite anxieties about the saftey of ROD, this procedure can be safely carried out in the patients' own homes without direct medical or nursing involvement; and to evaluate effectiveness in the sense of continuing NTX treatment. We also discuss the financial and therapeutic implications for opiate withdrawal programmes. Material and methods This is a descriptive, open-iabel study in which, after screening and baseline assessments, patients start a detoxification and naltrexone induetion programme. The main part of this study involves 1368 outpatients from the two participating centres, the detoxification outpatient unit of the Central Hospital of Asturias, Oviedo and the Clinica Médico Psicológica Asturias, Gijón between January 1994 and January The hospital detoxification unit is situated in the Central Hospital, which belongs to the Spanish National Health Servíce. The Clínica Médico Psicológica Asturias is a private entity. ExactIy the same procedure was used in both centres. Fifteen and 25%, respectively, of the detoxifications performed in the region are carried out in these two establishments. Patients had a choice of detoxification methods, the usual alternative being a day inpatient methadone reduction programme using clonidine and some sedation. During the same period, approximately 3500 patients chose the alternative programme. Patients who were accepted for treatment had to comply with ICD-10 criteria for opiate dependence, to be 18 years or over and to give informed consent. We did not exclude patients with mild non-dependent abuse of alcohol, benzodiazepines or cocaine. We accepted patients who had taken regularly up to 2 g of heroin per day (or other opiate equivalent). Those patients who had the procedure immediately after having failed to complete a more classical detoxification were not included. During the study period, 1414

3 24-Hour opiate detoxifieation and antagonist induction at home 245 Table l. Medication protocol Time First dose Baseline Second dose 45 rninutes Third dose 1 hour 45 minutes Drug Callrnedication oral) Clonidine 0.450rng Famotidine 40 rng Loperamide 4 rng Midazolarn 22.5 rng Ondansetron 12rng Clorazepate 50 rng Metoc1opramide 10 rng Naltrexone 50 rng Hyoscine butylbromide 20 rng Clonidine rng Metoc1oprarnide 10 rng patients requested RAI and 46 were rejeeted because of various contraindications: pregnancy 8.7%; pulmonary disease 52.2%; arrythmia or conduction disorder 17.4%; angina 4.3%; duodenal ulcer 4.3%; epilepsy 2.2%; lack of suitable family support 10.9%. The exclusion rate was therefore 3.25%. Treatment regimen Initial eonsultation The initial consultation included a semi-structured interview (including the responsible carer) confirmation of the patient's claimed drug use by urinalysis, physical examination, ECG and standard haematology/biochemistry tests. It also included a detailed explanation of the procedure to the patient and responsible family member, discussion of risks and potential problems, confirming telephone contacts and obtaining written consent. The medication decribed in Table 1 was then given to the carerothe same doses were used for all patients. All drugs are taken orally, with the exception of oetreotide, recently added to the protocol as an antidiarrhoeal (see below). Treatment is then (or the following day, if the first consultation took place in the evening, for example) initiated in the patient's home under the supervision of the carer, who maintains close telephone contact with the medical team involved. Deseription o/ a typieal proeedure Patients were advised to take no opiates for 12 hours before the procedure. The rationale was Psychiatric condition Family/social Legal situation Other substances Alcohol Employment Medical condition 0-1 No problems 2-3 Slight trouble 4-5 Moderate problems 6-7 severe problems 1 o Figure 1. Europ AS! based analysis of data obtained N = 800 (information as from September 1996).

4 246 J. E. Carreño et al. that this might reduce the severity of the precipitated withdrawal, but failure to follow this advice was not a reason for abandoning treatment. Similarly, patients were advised to minimize the use of other classes of drug, including alcohol. After swallowing the ondansetron, clonidine, midazolam, cworazepate, famotidine and loperamide, most patients are asleep after 30 minutes but are easily wakened to swallow the naltrexone and metoclopramide at 45 minutes. They then go back to sleep for about 30 minutes before the naltrexone-precipitated withdrawal starts. The range and intensity of withdrawal symptoms are shown in Fig. 1. The most visible manifestation is restlessness, which ranges from occasional movements during sleep to attempts to walk around the room. Patients are often confused and incoherent,17,18 but are generally able to indicate a desire to defaecate or pass urine and can usually walk with assistance. This stage is usually handled without much difficulty by the carers. Confusion and restlessness typically abate after 4-6 hours and nearly all patients are well enough to attend the clinic the next day for a further dos e of naltrexone and assessment (see below). Second consultation (24 hours later) Physical examination (further medication given if withdrawal symtoms persist). Completion of Gold's Scale and EuropASI (European adaptation of the fifth American edition of the Addiction Severity Index).19 Start of naltrexone maintenance programme with additional psychosocial therapy as indicated. Third consultation (96 hours later) Continuation of the naltrexone maintenance programme. Results Demographic data Eighty-two per cent of the 1368 were maleo Average age was 26.2 years; 62% were single. Thirty-one per cent were in regular employment and 51 % were unemployed. Seventy-two per cent had only basic education. Eighty-seven per cent used heroin only, 8% used methadone only, 5% used both. Average duration of habit was 4.9 years. Average time since last relapse was 9 months. Of the heroin users, 69% smoked it; 65% used between 0.25 and 0.5 g daily, 28% used g daily, 7% used > 1 g. Seventy-six per cent had previously been in treatment, with an average of four episodes. The results of the EuropASI are given in Fig. l. Since the object of treatment is not simply to accelerate the detoxification process but also to initiate naltrexone maintenance treatment, one simple and practical measure of effectiveness is the proportion of patients who returned for at least a second dose of naltrexone within 24 hours. Only three patients failed to do so. Effectiveness by this criterion was therefore 99.8%. Patients reported the following withdrawal symptoms: vomiting 172 (12.6%), diarrhoea 201 (14.7%), abdominal cramps 73 (5.3%) delirium 2 (0.1 %) and side effects of medication: hypotension 36 (2.6%), bradycardia 12 (0.9%), extrapyramidal syndrome five (0.4%). Twenty-four patients (1.8%) were admitted to hospital for rehydration. There were no cases of hypersedation or respiratory depression. Rating with Gold's Modified Scale indicated only a moderate degree of withdrawal discomfort overall at 24 hours (see Fig. 2). Discussion This study shows that it is possible for a full (50 mg) dose of naltrexone to be given to large numbers of typical opiate-dependent patients, who had generally taken their usual dose of opiate (heroin and/or methadone) within the previous 24 hours, without deaths or serious complications. Family members with only minimal instruction were able to manage the resultant acute antagonist-precipitated withdrawal in all but 1.75% of these patients. Although 24 patients were taken to hospital, most needed only advice and reassurance and none of them required more than a brief admission for rehydration. The introduction of octreotide (see below) should make this complication even more rare. It also makes the protocol similar to that described by Bell et al., 18who also used comparatively light oral sedation and reported no serious complications in 30 cases. Since ours is by far the largest reported series of patients receiving RODIRAI, the results indicate that this protocol has a low risk of significant adverse events. Including the subjects of this study, a total of more than 3000 patients have been treated in Asturias with this technique (as ofsummer 2001) without significant complications.

5 24-Hour opiate detoxifieadon and antagonist induetion at home 247 Anxiety Yawning Sweating Lachrymation Rhinorrhea Mydriasis Piloerection Tremors Shivering Muscle aches Insomnia Hypertension Temperature :::::::J :::::J Restlessness Respiratory depression Agitation E~~~~~~~~~~~~~~~~~~=:J E==:::J ~~~~~~~~~~~~~===:J Nausea Vomiting Tachycardia Diarrhoea Spontaneous ejaculation I I O Figure 2. Evaluation o/ withdrawal symptoms (Gold's rnodified scale) The total cost ofthis domiciliary RAI ( pesetas = approximately D40, 240 or USS230 (including medication, medical examinations and laboratory tests) is quite low. It compares favourably with typical published costs for outpatient detoxification, especially if one considers the cost per suceessful detoxification, as Gossop & Strang2 have pointed out. While a small number of deaths and serious complications have been reported in association with ROD/RAI procedures, nearly all have followed the administration of general anaesthesia or much larger doses of oral or parenteral benzodiazepines than are required with this protocol. Most of the deaths involved patients treated by organizations which have been criticized for their excessive commercialization of ROD procedures using anaesthesia.16 Significantly, one of them (the CITA organization) has consistently denied that any deaths or serious complications have occurred)21 even though at least two have been documented22,23 and an independent follow-up study of CITA patients included the information that one had a cardiac arrest shortly after extubation which responded to treatment.24 Treatment in an intensive care unit with intravenous access provides close monitoring and precise control of medications. Theoretically, this should reduce the risk of complications and ensure a rapid and skilled response to any complications that do occur. In praetice, it seems that invasive procedures such as nasogastric or endotracheal intubation, and the use of propofol or midazolam in high rather than low doses, may sometimes cause problems as well as alleviating them.25 For example, high doses of propofol or midazolam avoid the problem of restlessness or inadequate sedation but may be associated with respiratory complications in a few cases. However, techniques using intravenous sedation or anaesthesia/intubation in RODIRAI may be essential for patients with high sedative tolerance and certain medical or physical conditions requiring additional medication or an absence of restlessness. Maksoud (personal communication) has had no deaths or significant complications in over 5000 procedures using anaesthesia with thiopentone. At any rate our study clearly refutes the claim made by Javier Alvarez et al.26 that domiciliary techniques are too dangerous for routine use. The basic Asturian protocol evidently controls agitation and unease in most patients. Some studies have used antipsychotic drugs as well as benzodiazepines.27 However, these drugs do not necessarily provide adequate levels of amnesia or sedation, have prolonged actions and can be cardiotoxic. Oral midazolam is well absorbed, amnesiogenic and short-acting. Unlike neuroleptics, it also has a specific antagonist (flumazenil) in the event of overdosage. In Britain, it was thought inadvisable for medico-political reasons28-34 to ofier this treatment as a domiciliary procedure. Other faetors also influenced the decision to treat patients in an

6 248 J E. Carreño et al. inpatient setting. First, simple but apparently highly effective naltrexone implants had become available35-37and virtuaily abolished relapse during the crucial and vulnerable first month after RAl. For comparison, relapse occurred in 20% of an earlier cohort of 229 Asturian patients during the first month.29 Inserting a naltrexone implant during the procedure required a hospital setting. Secondly, although most Asturian patients reported adequate levels of symptom relief or amnesia for the acute precipitated withdrawal symptoms (as the increasing number of requests for this technique indicates) it may not be adquate in patients who were tolerant of benzodiazepines even if they were not dependent on them. Inpatient treatment for 24 hours means that additional doses of midazolam can be given in such cases, if necessary, before or after the administration of naltrexone. Further doses of octreotide, clonidine, antiemetics and analgesics can also be given in the minority of patients who report significant levels of distress on waking after 6-8 hours. Given that relapse is common in abstinence-based treatments and that many patients wiil need help to withdraw from opiates again at some stage after undergoing ROD/RAl, ensuring adequate relief or amnesia may minimize the proportion who report that they would not undergo such procedures again, or recommend them.18,30,31 Thirdly, following its initial use at the Stapleford Centre in ,32 experience in several centres (e.g. BeIl et al. 1999;18 Ali et al ) supported the impression that adding octreotide to the protocol greatly reduced the incidence of vomiting and diarrhoea. However, this drug has to be administered bys.c. (or Lv.) injection. In 110 Stapleford patients, the inclusion of 200 flg of octreotide in the premedication reduced the incidence of diarrhoea in the first 6 hours to 4% compared with the 15-65% reported in protocols of similar techniques not using octreotide, including the basic Asturian protocol as mentioned earlier. In Asturias, the protocol has therefore been modified since January 1999, to include 200 flgof octreotide S.C. 1 hour before the first oral dose. It is administered either at the clinic or by suitably instructed family members, depending on geographic and other factors. It replaces the opioid loperamide which, although used in several other ROD/RAl protocols, is probably largely or completely blocked by naltrexone. However, none of the 1368 patients in the main part of this study received octreotide. The results show that the combination of antiwithdrawal medication used in the basic protocol enabled most patients to get through the acute precipitated withdrawal with relatively modest levels of discomfort. However, vomiting was not controlled in ail cases and, like diarrhoea, it can be distressing for both patients and carers. BeIl et al. 18 found thal: ondansetron alone did not prevent vomiting and felt that octreotide was 'probably the most important' anti-emetic. Ali et al.33 reported that 64% of patients undergoing ROD but not receiving octreotide had vomiting andlor diarrhoea, against only 8% in the group receiving octreotide (p < 0.001) Should we conceptualize these procedures as rapid opiate detoxijication or as rapid antagonist induction (RAI)? The emphasis in several previous studies on rapid detoxijication (and the exaggerated and dishonest claims for 'painless' detoxification made by some providers) have diverted attention from the ability of ROD techniques to facilitate the induction of treatment with supervised or implanted naltrexone (or other antagonists existing or being developed). We therefore believe that the procedure should be conceptualized and referred to as rapid antagonist induction (RAl) instead of, or as weil as, ROn. Currie34 and Currie et al. 31 take a very similar view, but suggest the phrases 'rapid induction of opiate receptor blockade' (RIORB) or 'rapid induction onto naltrexone' (RION). We think the former acronym is cumbersome, while the latter ignores the fact that other antagonists such as chlornaltrexamine or nalmefene may be used, or are already being used, in place of naltrexone. For initiating antagonist treatment, naltrexone has obvious practical advantages over naloxone, which is short-acting and needs to be given by injection. Naltrexone is clearly the most appropriate of currently available antagonists for domiciliary treatment. However, there is evidence from some of the earliest studies2 and from very recent ones34,35 that repeated incremental naloxone injections may facilitate transfer to fuil doses of naltrexone after a few hours. In some protocols, nalmefene is used as the initiating antagonist. It has a slightly longer half-life than naltrexone and may be more potent.

7 24-Hour opiate detoxijication and antagonist induction at home 249 As regards the ideal dosage of naltrexone, obviously this must be at least sufficient to guarantee total blockade, normally regarded as 50 mg. Although an increased dose has sometimes been suggested36,37we do not consider this necessary, given that the majority of procedures using antagonists include a second dos e after 24 hours; Le. while the initial dose is still effective. Some studies conclude that increased doses do not seem to reduce the duration of treatment or reduce withdrawal intensity.38 However, McDonald et al.39 found that naltrexone absorbtion during ROD under anaesthesia was unexpectedly variable and negatively correlated with withdrawal symptoms 24 hours later. Another important question is whether ROD/ RAI should be reserved only for heroin addicts or whether it can be used for withdrawal from methadone or other long-acting synthetic opiates such as Laevo alpha acetyl methadone or buprenorphine. Methadone may cause more severe withdrawal symptoms than heroin in conventional procedures40,41 but RAI seems to equalize the withdrawal symptomatology.3,15,42,43currie et al.31 found no differences in acute withdrawal symptoms and only minor and short-lived differences in residual withdrawal symptoms for patients who had been taking methadone compared with patients withdrawing from heroin. However, it is particularly important that antagonist activity should be maintained for several days given the longer-iasting effects of these synthetic opioids, which could still be present in plasma and lead to rapid reoccupation of opiate receptors if naltrexone were discontinued after the first dose. The possible superiority of buprenorphine for RAI procedures remains to be confirmed. Like several other researchers, Currie et al. 31 found no correlation between severity or duration of withdrawal symptoms and the patient's normal daily opiate/opioid dose. However, their results supported a widely held belief that the time elapsed since the last opiate dose relates inversely to withdrawal severity. Studies providing data on post-detoxification monitoringi5,43-45 of both drug-free treatment as well as maintenence programmes with antagonists, reveal that retention in follow-up treatment depends on the type of treatment itself, but not on the initial method of detoxification. However, it is becoming increasingly clear that patients who undergo an RAI procedure are significantly more likely to start an antagonist maintenance programmei5,42,43 than those who have received a more conventional withdrawal and induction. The emphasis, therefore, in the treatment described here, should be on rapid antagonist induction rather than rapid opiate detoxification. References 1. Blachly P, Casey D, Marcel L et al. Rapid detoxification from heroin and methadone using naloxone. A model for study of the treatrnent of the opiate abstinence sindrome. In: Senay E, Shorty V, Alkesne H, editors. Development in the field of drug abuse. Cambridge, MA: Schenkman Publishing Co.; 1975, pp Resnick RB, Kestenbaum RS, Washton A, Poole D. Naloxone-precipitated withdrawal: a method for rapid induetion onto naltrexone. Clin Pharmacol Ther 1977;21: Charney DS, Riordan CE, Kleber HD et al. Clonidine and naltrexone: a safe, effective and rapid treatrnent of abrupt withdrawal from methadone therapy. Arch Gen Psychiatry 1982;39: Loimer N, Schmid R, Presslich O, Lenz K. Continuous naloxone administration suppresses opiate withdrawal symptoms in human opiate addiets during detoxification treatrnent. J. Psychiatr Res 1988;23: Brewer C, Rezae H, Bailey C. Opioid withdrawal and naltrexone induetion hours using a modification of the naltrexone-c1onidine technique. Br J Psychiatry 1988;153: Gerra G, Marcato A, Caccavari R. Clonidine and opiate receptor antagonists in the treatrnent of heroin addiction. J Subst Abuse Treat 1995;12: Chan KY. The Singapore naltrexone communitybased projeet for heroin addiets compared with drugfree cornmunity-based program: the first cohort. J Clin Forens Med 1996;3: Cornish JW, Metzger D, Woody GE et al. Naltrexone pharmacotherapy for opioid dependent federal probationers J Subst Abuse Treat 1997; 14: 9. Chick J, Gough K, Wojciech F et al. Disulfiram treatrnent of alcoholismo Br J Psychiatry 1992; 161: Brewer C, Meyers R, Johnsen J. Does disulfiram help to prevent relapse in alcohol abuse? CNS Drugs 2000;14: Laheij RlF, Krabbe PFM, De Jong CAJ. Rapid heroin detoxification under general anaesthesia. JAMA 2000;283: Brewer C. Ultra-rapid, antagonist-precipitated opiate detoxification under general anaesthesia or sedation. Addiet BioI1997;2; Himmelsbach CK. Clinical studies of drug addiction, physical dependence, withdrawal and recovery. Arch Int Med 1942;69: Alvarez FJ, Del Rio MC. Desintoxicaciones ultracortas: del triunfo de la farmacología a la innova-

8 250 J. E. Carreño et al. ción tecnológica. Rev Esp Drogodependencias 1998;23: Carreño]E, Sánchez del Río J, Oniz R et al. Pautas de Inducción Rápida Ambulatoria. Tres años de aplicación en Asturias. libro de Actas XXIV Jornadas Nacionales Socidrogalcohol 1997: 16. Brewer C, WilIiams J, Carreño ]E, Bobes J. Unethical promotion of rapid opiate detoxification under anaesthesia (RODA). Lancet 1998;351: Brewer C. Accelerated opioid withdrawal and naltrexone induction in one day [Abstraet]. Proceedings of the Internarional Congress on Alcohol, Other Drugs and the Family, Sydney, November 1988, p Bell IR, Young MR, Masterman SC, Morris A, Marrick RP, Bammer G. A pilot study of naltrexone-accelerated detoxifcarion in opioid dependence. Med J Aust 1999;171: McLellan AT, Kushner H, Metzger D et al. The fifth edirion of the Addiction Severity Index. J Subst Abuse Treat 1992;9: Gossop M, Strang J. Price, cost and value of opiate detoxificarion treatments. Br J Psychiatry 2000;177: Legarda JJ. Ultra-rapid opiate detoxificarion under anaesthesia CUROD). Lancet 1998;351: EIliott C, Mihill C. The strange death of Brendan WooIhead. Guardian (London) 1 May Blake S. Addict robbed of her new Iife. Sunday Telegraph (Sydney), 9 May Garcia-Comas L. Alcaide JF. Amate JM. Conde JL Legarda JJ. Evaluacion de la efectividad del tratamiento UROD asociado a rehabilitacion ulterior en pacientes dependientes de opiaceos. Rev Esp Drogodependencias 1998;23: Seoane A, Carrasco G, Cabre U, Puiggros A, Hernández E, A1varezM. Efficacy and safety of two methods of rapid intravenous detoxification in heroin addicts previously treated without success. Br J Psychiatry 1997;171: Javier A1varezF, Carmen Del Río M, San L, Arranz B. UItrarapid opiate detoxification: a look at what is happening in Spain. Pros and cons of ultrarapid opiate detoxificarion. Addiction 1999;94: London M, Paul E, Gkolia I. Ultra-rapid opiate detoxificarion in hospital. Psychiatr Bull 1999;23: Strang J, Bearn J, Gossop M. Opiate detoxification under anaesthesia 315: [Editorial]. Br Med J 1997; 29. Carreño Rendueles ]E, Orriz Jackson R, Sánchez del Río J, Álvarez Díaz, Calvo Rodriguez IR, Pérez González SE Pautas de induccion rapida. Modelos ambulatorios en Asturias. Psiquiatr Biol 1996; 13: 30. Tretter F, Burkhardt D, Bussello-Spieth, Reiss J, Walcher S, Buchele W. Clinical experience with antagonist-induced opiate withdrawal under anaesthesia. Addiction 1998;93: CurrieJ, Collins L, MudaliarY et al. Rapid induction onto naltrexone: a randomized c1inical trial of anesthesia-assisted versus sedation-assisted techniques, and a comparison with convenrional detoxification. Western Sydney Area Health Service Drug and Alcohol Service-Report to Government of New South Wales Brewer C. La octreórida en desintoxicación rápida de opiáceos. Rev Esp Drogodependencias 1999;24: Ali R, McGregor C, White J, Thomas P, Myburgh J, Gowing L. Randomised c1ínical tríal of heroin withdrawal under anaestheric prior to induction onto naltrexone maintenance therapy: outcomes at six months. Paper presented at APSAD annual meeting Sydney, November Currie J. RIORB or RION? A conceptual reevaluarion of the technique of rapid or ultra-rapid opiate detoxificarion. Paper presented at the 5th Stapleford International Symposium, Berlin, June, Hulse G, Basso MR. Reassessing naltrexone maintenance as a treatment for iiiicit heroin users. Drug Alcohol Rev 1999;18: Dona M, Valenciano R, Morera A, Henry M, Diaz Flores J. Desintoxicaciones activas. Otro abordaje de los tratamientos ultracortos. Rev Esp Drogodependencias 1998;23: Olcina J, Miñana L, Martin Ruiz JL, Salort Ronda J, Soler E. Un protocolo de desintoxicación ultracorta de opiáceos en medio hospitalario: evolución hacia una mayor seguridad y confort para el paciente. Rev Esp Drogodependencias 1999;23: Gurierrez M, Ballesteros J, Figuerido JL. Las desintoxicaciones ultraconas con antagonistas opiaceos. In: Casas M, Gutierrez M, San L, editors. Avances en Drogodependencias, tratamiento farmacológico, 1st edn. Barcelona: Ediciones en Neurociencias; McDonald T, Berkowitz R, Hoffman W Plasma naltrexone during opioid detoxificarion. J Addict Dis 2000;19: B1achly PH. Naloxone for diagnosis in methadone programs. JAMA 1973;224: Strang J, Gossop M. Comparison of linear versus inverse exponential methadone reducrion curves in the detoxificarion of opiate addicts. Addict Behav 1990;15: Elizagarate E, Gutiérrez M, Figueirido JL, Gonzalez-Pinto A, Jimenez Lerma JM, Fernandez Gomez C. Antagonización Rápida de Opiáceos. Rev Esp Drogodependencias 1999;23: Carreño ]E, Bobes J, Sánchez del Río J et al. Pautas de Antagonización Rápida Ambulatoria en dependientes de opiáceos. Análisis compararivo. Rev Esp Drogodependencias 1998;23: Gurierrez M. Nuevas indicaciones de la Naltrexona. Desintoxicaciones cortas y ultracortas. In: 11 Drug Addiction Medical November Forum, lisboa, Seoane A, Puiggros A, Hernández A. Estudio de los tratamientos de desintoxicación ultracortos (24 horas). Rev Psiquiatr Fac Med Barc 1996;23:

Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification. Original Policy Date

Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification. Original Policy Date MP 3.01.02 Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification Medical Policy Section Mental Health Issue 12:2013 Original Policy Date 12:2013 Last Review

More information

Behavioral Health Policy: Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction

Behavioral Health Policy: Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction Behavioral Health Policy: Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction Table of Contents Policy: Commercial Coding Information Information Pertaining

More information

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY Original Issue Date (Created): 12/8/2003 Most Recent Review Date (Revised): 3/24/2015 Effective Date: 6/1/2015 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS

More information

COMMUNITY BUPRENORPHINE PRESCRIBING IN OPIATE DEPENDENCE

COMMUNITY BUPRENORPHINE PRESCRIBING IN OPIATE DEPENDENCE COMMUNITY BUPRENORPHINE PRESCRIBING IN OPIATE DEPENDENCE INTRODUCTION High dose sublingual buprenorphine (Subutex) tablets are available in the following strengths 0.4 mg, 2 mg, and 8 mg. Suboxone tablets,

More information

18 Clonidine and Lofexidine: New Nonopiate Treatments for Opiate Withdrawal

18 Clonidine and Lofexidine: New Nonopiate Treatments for Opiate Withdrawal INTRODUCTION Recent studies (Gold et al, 1978; Washton et al, 1980a) showing that the non-opiate antihypertensive agent, clonidine hydrochloride, suppresses signs and symptoms of opiate withdrawal, have

More information

New York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery

New York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery New York State Office of Alcoholism & Substance Abuse Services Addiction Services for Prevention, Treatment, Recovery USING THE 48 HOUR OBSERVATION BED USING THE 48 HOUR OBSERVATION BED Detoxification

More information

Buprenorphine: what is it & why use it?

Buprenorphine: what is it & why use it? Buprenorphine: what is it & why use it? Dr Nicholas Lintzeris, MBBS, PhD, FAChAM Locum Consultant, Oaks Resource Centre, SLAM National Addiction Centre, Institute of Psychiatry Overview of presentation

More information

Medical Policy Manual. Date of Origin: August 1999

Medical Policy Manual. Date of Origin: August 1999 Medical Policy Manual Topic: Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification Section: Behavioral Health Policy No: 14 Date of Origin: August 1999 Last

More information

Assessment and Management of Opioid, Benzodiazepine, and Sedative-Hypnotic Withdrawal

Assessment and Management of Opioid, Benzodiazepine, and Sedative-Hypnotic Withdrawal Assessment and Management of Opioid, Benzodiazepine, and Sedative-Hypnotic Withdrawal Roger Cicala, M. D. Assistant Medical Director Tennessee Physician s Wellness Program Step 1 Don t 1 It is legal in

More information

Rapid Methadone Detoxification using Morphine to Reduce Severity of Withdrawal

Rapid Methadone Detoxification using Morphine to Reduce Severity of Withdrawal Rapid Methadone Detoxification using Morphine to Reduce Severity of Withdrawal Dr Ross Colquhoun, D H Sc, M App Sc (Neuroscience), B Sc Hons (Psych), Grad Dip Counselling and Psychotherapy Research Fellow

More information

Page 2 of 10. Proprietary Information of Blue Cross and Blue Shield of Alabama Medical Policy #091

Page 2 of 10. Proprietary Information of Blue Cross and Blue Shield of Alabama Medical Policy #091 Name of Policy: Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification Policy #: 091 Latest Review Date: January 2015 Category: Mental Health/Pharmacology

More information

MEDICAL POLICY SUBJECT: OPIOID ADDICTION TREATMENT. POLICY NUMBER: 3.01.04 CATEGORY: Behavioral Health

MEDICAL POLICY SUBJECT: OPIOID ADDICTION TREATMENT. POLICY NUMBER: 3.01.04 CATEGORY: Behavioral Health MEDICAL POLICY SUBJECT: OPIOID ADDICTION TREATMENT PAGE: 1 OF: 6 If the member's subscriber contract excludes coverage for a specific service it is not covered under that contract. In such cases, medical

More information

File No 00/1287 Circular No 2001/17. Issued 23 February 2001. Contact. Guidelines for Rapid Detoxification from Opioids

File No 00/1287 Circular No 2001/17. Issued 23 February 2001. Contact. Guidelines for Rapid Detoxification from Opioids CIRCULAR File No 00/1287 Circular No 2001/17 Issued 23 February 2001 Contact Anthony Jackson (02) 9391 9538 Drug Programs Bureau Guidelines for Rapid Detoxification from Opioids This Circular should be

More information

Update on Buprenorphine: Induction and Ongoing Care

Update on Buprenorphine: Induction and Ongoing Care Update on Buprenorphine: Induction and Ongoing Care Elizabeth F. Howell, M.D., DFAPA, FASAM Department of Psychiatry, University of Utah School of Medicine North Carolina Addiction Medicine Conference

More information

Care Management Council submission date: August 2013. Contact Information

Care Management Council submission date: August 2013. Contact Information Clinical Practice Approval Form Clinical Practice Title: Acute use of Buprenorphine for the Treatment of Opioid Dependence and Detoxification Type of Review: New Clinical Practice Revisions of Existing

More information

1. According to recent US national estimates, which of the following substances is associated

1. According to recent US national estimates, which of the following substances is associated 1 Chapter 36. Substance-Related, Self-Assessment Questions 1. According to recent US national estimates, which of the following substances is associated with the highest incidence of new drug initiates

More information

Integrating Medication- Assisted Treatment (MAT) for Opioid Use Disorders into Behavioral and Physical Healthcare Settings

Integrating Medication- Assisted Treatment (MAT) for Opioid Use Disorders into Behavioral and Physical Healthcare Settings Integrating Medication- Assisted Treatment (MAT) for Opioid Use Disorders into Behavioral and Physical Healthcare Settings All-Ohio Conference 3/27/2015 Christina M. Delos Reyes, MD Medical Consultant,

More information

Treatment of Opioid Dependence with Buprenorphine/Naloxone (Suboxone )

Treatment of Opioid Dependence with Buprenorphine/Naloxone (Suboxone ) Treatment of Opioid Dependence with Buprenorphine/Naloxone (Suboxone ) Elinore F. McCance-Katz, M.D., Ph.D. Professor and Chair, Addiction Psychiatry Virginia Commonwealth University Neurobiology of Opiate

More information

Treatment of opioid use disorders

Treatment of opioid use disorders Treatment of opioid use disorders Gerardo Gonzalez, MD Associate Professor of Psychiatry Director, Division of Addiction Psychiatry Disclosures I have no financial conflicts to disclose I will review evidence

More information

NALTREXONE INDUCED DETOXIFICATION FROM OPIOIDS A METHOD OF ANTAGONIST INITIATED TREATMENT

NALTREXONE INDUCED DETOXIFICATION FROM OPIOIDS A METHOD OF ANTAGONIST INITIATED TREATMENT NALTREXONE INDUCED DETOXIFICATION FROM OPIOIDS A METHOD OF ANTAGONIST INITIATED TREATMENT Opioid dependence is a devastating and frequently fatal medical condition. It is a manifestation of addictive disorder

More information

DRUG AND ALCOHOL DETOXIFICATION: A GUIDE TO OUR SERVICES

DRUG AND ALCOHOL DETOXIFICATION: A GUIDE TO OUR SERVICES 01736 850006 www.bosencefarm.co.uk DRUG AND ALCOHOL DETOXIFICATION: A GUIDE TO OUR SERVICES An environment for change Boswyns provides medically-led drug and alcohol assessment, detoxification and stabilisation.

More information

SCOTTISH PRISON SERVICE DRUG MISUSE AND DEPENDENCE OPERATIONAL GUIDANCE

SCOTTISH PRISON SERVICE DRUG MISUSE AND DEPENDENCE OPERATIONAL GUIDANCE SCOTTISH PRISON SERVICE DRUG MISUSE AND DEPENDENCE OPERATIONAL GUIDANCE 1 P a g e The following Operational Guidance Manual has been prepared with input from both community and prison addictions specialists

More information

Rapid Opioid Detoxification - Guidelines

Rapid Opioid Detoxification - Guidelines Guideline Rapid Opioid Detoxification - Guidelines Document Number GL2011_009 Publication date 21-Jul-2011 Functional Sub group Clinical/ Patient Services - Medical Treatment Department of Health, NSW

More information

One example: Chapman and Huygens, 1988, British Journal of Addiction

One example: Chapman and Huygens, 1988, British Journal of Addiction This is a fact in the treatment of alcohol and drug abuse: Patients who do well in treatment do well in any treatment and patients who do badly in treatment do badly in any treatment. One example: Chapman

More information

Medications for Alcohol and Drug Dependence Treatment

Medications for Alcohol and Drug Dependence Treatment Medications for Alcohol and Drug Dependence Treatment Robert P. Schwartz, M.D. Medical Director Rschwartz@friendsresearch.org Friends Research Institute Medications for Alcohol Dependence Treatment Disulfiram

More information

EPIDEMIOLOGY OF OPIATE USE

EPIDEMIOLOGY OF OPIATE USE Opiate Dependence EPIDEMIOLOGY OF OPIATE USE Difficult to estimate true extent of opiate dependence Based on National Survey of Health and Mental Well Being: 1.2% sample used opiates in last 12 months

More information

Interference with withdrawal signs of naloxone-induced opiate withdrawal under anesthesia is anesthetic-specific in opiate-dependent rats

Interference with withdrawal signs of naloxone-induced opiate withdrawal under anesthesia is anesthetic-specific in opiate-dependent rats Life Sciences 70 (2001) 517 522 Interference with withdrawal signs of naloxone-induced opiate withdrawal under anesthesia is anesthetic-specific in opiate-dependent rats Emmanuel Streel a, *, Bernard Dan

More information

Issues around Naltrexone Implants

Issues around Naltrexone Implants Issues around Naltrexone Implants Dr Lucy Cockayne Consultant Addiction Psychiatrist. Lanarkshire Primary Care Trust Maintenance with antagonists? the great disproportion seen in favour of programmes with

More information

Using Buprenorphine to Treat Acute Opioid Withdrawal in the ED

Using Buprenorphine to Treat Acute Opioid Withdrawal in the ED Using Buprenorphine to Treat Acute Opioid Withdrawal in the ED Dr. Karine Meador MD CCFP DABAM Assistant Director Inner City Health and Wellness Team Physician Addiction Recovery and Community Health (ARCH)

More information

Opioids Research to Practice

Opioids Research to Practice Opioids Research to Practice CRIT Program May 2011 Daniel P. Alford, MD, MPH Associate Professor of Medicine Boston University School of Medicine Boston Medical Center 32 yo female brought in after heroin

More information

Treatments for drug misuse

Treatments for drug misuse Understanding NICE guidance Information for people who use NHS services Treatments for drug misuse NICE clinical guidelines advise the NHS on caring for people with specific conditions or diseases and

More information

Information for Pharmacists

Information for Pharmacists Page 43 by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Information for Pharmacists SUBOXONE (buprenorphine HCl/naloxone HCl

More information

Use of Buprenorphine in the Treatment of Opioid Addiction

Use of Buprenorphine in the Treatment of Opioid Addiction Use of Buprenorphine in the Treatment of Opioid Addiction Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Executive Summary Which of the following is an

More information

Treatment of Opioid Dependence: A Randomized Controlled Trial. Karen L. Sees, DO, Kevin L. Delucchi, PhD, Carmen Masson, PhD, Amy

Treatment of Opioid Dependence: A Randomized Controlled Trial. Karen L. Sees, DO, Kevin L. Delucchi, PhD, Carmen Masson, PhD, Amy Category: Heroin Title: Methadone Maintenance vs 180-Day psychosocially Enriched Detoxification for Treatment of Opioid Dependence: A Randomized Controlled Trial Authors: Karen L. Sees, DO, Kevin L. Delucchi,

More information

MEDICALLY SUPERVISED OPIATE WITHDRAWAL FOR THE DEPENDENT PATIENT. An Outpatient Model

MEDICALLY SUPERVISED OPIATE WITHDRAWAL FOR THE DEPENDENT PATIENT. An Outpatient Model MEDICALLY SUPERVISED OPIATE WITHDRAWAL FOR THE DEPENDENT PATIENT An Outpatient Model OBJECTIVE TO PRESENT A PROTOCOL FOR THE EVALUATION AND TREATMENT OF PATIENTS WHO ARE CHEMICALLY DEPENDENT ON OR SEVERLY

More information

MOH CLINICAL PRACTICE GUIDELINES 2/2008 Prescribing of Benzodiazepines

MOH CLINICAL PRACTICE GUIDELINES 2/2008 Prescribing of Benzodiazepines MOH CLINICL PRCTICE GUIELINES 2/2008 Prescribing of Benzodiazepines College of Family Physicians, Singapore cademy of Medicine, Singapore Executive summary of recommendations etails of recommendations

More information

Minimum Insurance Benefits for Patients with Opioid Use Disorder The Opioid Use Disorder Epidemic: The Evidence for Opioid Treatment:

Minimum Insurance Benefits for Patients with Opioid Use Disorder The Opioid Use Disorder Epidemic: The Evidence for Opioid Treatment: Minimum Insurance Benefits for Patients with Opioid Use Disorder By David Kan, MD and Tauheed Zaman, MD Adopted by the California Society of Addiction Medicine Committee on Opioids and the California Society

More information

Heroin. How is Heroin Abused? What Other Adverse Effects Does Heroin Have on Health? How Does Heroin Affect the Brain?

Heroin. How is Heroin Abused? What Other Adverse Effects Does Heroin Have on Health? How Does Heroin Affect the Brain? Heroin Heroin is a synthetic opiate drug that is highly addictive. It is made from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears

More information

OPIOIDS. Petros Levounis, MD, MA Chair Department of Psychiatry Rutgers New Jersey Medical School

OPIOIDS. Petros Levounis, MD, MA Chair Department of Psychiatry Rutgers New Jersey Medical School OPIOIDS Petros Levounis, MD, MA Chair Department of Psychiatry Rutgers New Jersey Medical School Rutgers New Jersey Medical School Fundamentals of Addiction Medicine Summer Series Newark, NJ July 24, 2013

More information

Medication-Assisted Treatment (MAT) & What It Means Long-Term Gary K. Byrd., M.Ed., MAC, CCS, CAMS Methadone is the Gold Standard for treatment of chronic heroin addiction Gary Byrd 2015 1 Gary Byrd 2015

More information

Substitution Therapy for Opioid Dependence The Role of Suboxone. Mandy Manak, MD, ABAM, CCSAM Methadone 101-Hospitalist Workshop, October 3, 2015

Substitution Therapy for Opioid Dependence The Role of Suboxone. Mandy Manak, MD, ABAM, CCSAM Methadone 101-Hospitalist Workshop, October 3, 2015 Substitution Therapy for Opioid Dependence The Role of Suboxone Mandy Manak, MD, ABAM, CCSAM Methadone 101-Hospitalist Workshop, October 3, 2015 Objectives Recognize the options available in treating opioid

More information

Adjunctive psychosocial intervention. Conditions requiring dose reduction. Immediate, peak plasma concentration is reached within 1 hour.

Adjunctive psychosocial intervention. Conditions requiring dose reduction. Immediate, peak plasma concentration is reached within 1 hour. Shared Care Guideline for Prescription and monitoring of Naltrexone Hydrochloride in alcohol dependence Author(s)/Originator(s): (please state author name and department) Dr Daly - Consultant Psychiatrist,

More information

Heroin. How Is Heroin Abused? How Does Heroin Affect the Brain? What Other Adverse Effects Does Heroin Have on Health?

Heroin. How Is Heroin Abused? How Does Heroin Affect the Brain? What Other Adverse Effects Does Heroin Have on Health? Heroin Heroin is an opiate drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears as a white or brown

More information

Medications Used in the Treatment of Addiction Developed by Randall Webber, MPH. Alcohol Withdrawal

Medications Used in the Treatment of Addiction Developed by Randall Webber, MPH. Alcohol Withdrawal Medications Used in the Treatment of Addiction Developed by Randall Webber, MPH Alcohol Withdrawal MEDICATION Long/intermediateacting benzodiazepines (e.g., chlordiazepoxide/ Librium, diazepam/valium)

More information

To detox or not to detox: whose choice is it anyway? Dr Ed Day Senior Lecturer in Addiction Psychiatry University of Birmingham

To detox or not to detox: whose choice is it anyway? Dr Ed Day Senior Lecturer in Addiction Psychiatry University of Birmingham To detox or not to detox: whose choice is it anyway? Dr Ed Day Senior Lecturer in Addiction Psychiatry University of Birmingham What do people say they want? Luty J (2004) 104 people attending a community

More information

Joanna L. Starrels. 2 ND YEAR RESEARCH ELECTIVE RESIDENT S JOURNAL Volume VIII, 2003-2004. A. Study Purpose and Rationale

Joanna L. Starrels. 2 ND YEAR RESEARCH ELECTIVE RESIDENT S JOURNAL Volume VIII, 2003-2004. A. Study Purpose and Rationale Outpatient Treatment of Opiate Dependence with Sublingual Buprenorphine/Naloxone versus Methadone Maintenance: a Randomized Trial of Alternative Treatments in Real Life Settings Joanna L. Starrels A. Study

More information

Opioids Research to Practice

Opioids Research to Practice Opioids Research to Practice CRIT/FIT 2015 May 2015 Daniel P. Alford, MD, MPH, FACP, FASAM Associate Professor of Medicine Assistant Dean, Continuing Medical Education Director, Clinical Addiction Research

More information

Prior Authorization Guideline

Prior Authorization Guideline Prior Authorization Guideline Guideline: CSD - Suboxone Therapeutic Class: Central Nervous System Agents Therapeutic Sub-Class: Analgesics and Antipyretics (Opiate Partial Agonists) Client: County of San

More information

Dosing Guide. For Optimal Management of Opioid Dependence

Dosing Guide. For Optimal Management of Opioid Dependence Dosing Guide For Optimal Management of Opioid Dependence KEY POINTS The goal of induction is to safely suppress opioid withdrawal as rapidly as possible with adequate doses of Suboxone (buprenorphine HCl/naloxone

More information

Cigna Medical Coverage Policy

Cigna Medical Coverage Policy Cigna Medical Coverage Policy Subject Ultra-Rapid Detoxification Table of Contents Coverage Policy... 1 General Background... 1 Coding/Billing Information... 4 References... 5 Policy History... 7 Effective

More information

Naltrexone Shared Care Guideline for the treatment of alcohol dependence and opioid dependance

Naltrexone Shared Care Guideline for the treatment of alcohol dependence and opioid dependance Naltrexone Shared Care Guideline for the treatment of alcohol dependence and opioid dependance Introduction Indication/Licensing information: Naltrexone is licensed for use as an additional therapy, within

More information

Considerations in Medication Assisted Treatment of Opiate Dependence. Stephen A. Wyatt, D.O. Dept. of Psychiatry Middlesex Hospital Middletown, CT

Considerations in Medication Assisted Treatment of Opiate Dependence. Stephen A. Wyatt, D.O. Dept. of Psychiatry Middlesex Hospital Middletown, CT Considerations in Medication Assisted Treatment of Opiate Dependence Stephen A. Wyatt, D.O. Dept. of Psychiatry Middlesex Hospital Middletown, CT Disclosures Speaker Panels- None Grant recipient - SAMHSA

More information

Update and Review of Medication Assisted Treatments

Update and Review of Medication Assisted Treatments Update and Review of Medication Assisted Treatments for Opiate and Alcohol Use Disorders Richard N. Whitney, MD Medical Director Addiction Services Shepherd Hill Newark, Ohio Medication Assisted Treatment

More information

Heroin. How Is Heroin Abused? How Does Heroin Affect the Brain? What Other Adverse Effects Does Heroin Have on Health?

Heroin. How Is Heroin Abused? How Does Heroin Affect the Brain? What Other Adverse Effects Does Heroin Have on Health? Heroin Heroin is an opiate drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears as a white or brown

More information

Acute & Chronic Pain Management (requiring opioid analgesics) in Patients Receiving Pharmacotherapy for Opioid Addiction

Acute & Chronic Pain Management (requiring opioid analgesics) in Patients Receiving Pharmacotherapy for Opioid Addiction Acute & Chronic Pain Management (requiring opioid analgesics) in Patients Receiving Pharmacotherapy for Opioid Addiction June 9, 2011 Tufts Health Care Institute Program on Opioid Risk Management Daniel

More information

Treatment and Interventions for Opioid Addictions: Challenges From the Medical Director s Perspective

Treatment and Interventions for Opioid Addictions: Challenges From the Medical Director s Perspective Treatment and Interventions for Opioid Addictions: Challenges From the Medical Director s Perspective Dale K. Adair, MD Medical Director/Chief Psychiatric Officer OMHSAS 1 Treatment and Interventions for

More information

Alcohol and Drug. A Cochrane Handbook. losief Abraha MD. Cristina Cusi MD. Regional Health Perugia

Alcohol and Drug. A Cochrane Handbook. losief Abraha MD. Cristina Cusi MD. Regional Health Perugia Alcohol and Drug A Cochrane Handbook losief Abraha MD Regional Health Perugia of Cristina Cusi MD Outpatient Services - Neurology Clinical Institutes of Specialisation Milan Italy A John Sons, Ltd., THE

More information

Prior Authorization Guideline

Prior Authorization Guideline Prior Authorization Guideline Guideline: PDP IBT Inj - Vivitrol Therapeutic Class: Central Nervous System Agents Therapeutic Sub-Class: Opiate Antagonist Client: 2007 PDP IBT Inj Approval Date: 2/20/2007

More information

Maintenance treatment with depot opioid antagonists in subcutaneous implants: an alternative in the treatment of opioid dependence

Maintenance treatment with depot opioid antagonists in subcutaneous implants: an alternative in the treatment of opioid dependence Addiction Biology (December 2003) 8, 429 438 APPLIED RESEARCH Maintenance treatment with depot opioid antagonists in subcutaneous implants: an alternative in the treatment of opioid dependence J. E. CARREÑO,

More information

Guidance for Disease Management in Correctional Settings OPIOID DETOXIFICATION

Guidance for Disease Management in Correctional Settings OPIOID DETOXIFICATION 1145 W. Diversey Pkwy. 773-880-1460 Chicago, Illinois 60614 www.ncchc.org Guidance for Disease Management in Correctional Settings OPIOID DETOXIFICATION NCCHC issues guidance to assist correctional health

More information

Using Drugs to Treat Drug Addiction How it works and why it makes sense

Using Drugs to Treat Drug Addiction How it works and why it makes sense Using Drugs to Treat Drug Addiction How it works and why it makes sense Jeff Baxter, MD University of Massachusetts Medical School May 17, 2011 Objectives Biological basis of addiction Is addiction a chronic

More information

Impact of Systematic Review on Health Services: The US Experience

Impact of Systematic Review on Health Services: The US Experience Impact of Systematic Review on Health Services: The US Experience Walter Ling MD Integrated Substance Abuse Programs (ISAP) UCLA The effectiveness of interventions for addictions: The Drug and Alcohol

More information

Co-morbid physical disorders e.g. HIV, hepatitis C, diabetes, hypertension. Medical students will gain knowledge in

Co-morbid physical disorders e.g. HIV, hepatitis C, diabetes, hypertension. Medical students will gain knowledge in 1.0 Introduction Medications are used in the treatment of drug, alcohol and nicotine dependence to manage withdrawal during detoxification, stabilisation and substitution as well as for relapse prevention,

More information

KAP Keys. For Physicians. Based on TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment. of Opioid Addiction

KAP Keys. For Physicians. Based on TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment. of Opioid Addiction Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction Knowledge Application Program KAP Keys For Physicians Based on TIP 40 Clinical Guidelines for the Use of Buprenorphine

More information

Clinical case of rapid opiate detoxification under anesthesia.

Clinical case of rapid opiate detoxification under anesthesia. Clinical case of rapid opiate detoxification under anesthesia. Ramón Eloy Perdomo Gutiérrez, MD Hospital Universitario General Calixto García La Habana, Cuba. perdo@infomed.sld.cu Summary Feminine patient

More information

Opioid Treatment Services, Office-Based Opioid Treatment

Opioid Treatment Services, Office-Based Opioid Treatment Optum 1 By United Behavioral Health U.S. Behavioral Health Plan, California Doing Business as OptumHealth Behavioral Solutions of California ( OHBS-CA ) 2015 Level of Care Guidelines Opioid Treatment Services,

More information

Use of Vivitrol for Alcohol and Opioid Addiction

Use of Vivitrol for Alcohol and Opioid Addiction Use of Vivitrol for Alcohol and Opioid Addiction Ken Bachrach, Ph.D. Clinical Director, Tarzana Treatment Centers, Inc. kbachrach@tarzanatc.org What is Vivitrol? An injectable from of naltrexone, which

More information

Naltrexone Pellet Treatment for Opiate, Heroin, and Alcohol Addiction. Frequently Asked Questions

Naltrexone Pellet Treatment for Opiate, Heroin, and Alcohol Addiction. Frequently Asked Questions Naltrexone Pellet Treatment for Opiate, Heroin, and Alcohol Addiction Frequently Asked Questions What is Naltrexone? Naltrexone is a prescription drug that effectively blocks the effects of heroin, alcohol,

More information

Program Assistance Letter

Program Assistance Letter Program Assistance Letter DOCUMENT NUMBER: 2004-01 DATE: December 5, 2003 DOCUMENT TITLE: Use of Buprenorphine in Health Center Substance Abuse Treatment Programs TO: All Bureau of Primary Health Care

More information

Frequently asked questions

Frequently asked questions Naltrexone Pellet Treatment for Opiate, Heroin, and Alcohol Addiction Frequently asked questions What is Naltrexone? Naltrexone is a prescription drug that completely blocks the effects of all opioid drugs

More information

Opioid Addiction and Methadone: Myths and Misconceptions. Nicole Nakatsu WRHA Practice Development Pharmacist

Opioid Addiction and Methadone: Myths and Misconceptions. Nicole Nakatsu WRHA Practice Development Pharmacist Opioid Addiction and Methadone: Myths and Misconceptions Nicole Nakatsu WRHA Practice Development Pharmacist Learning Objectives By the end of this presentation you should be able to: Understand how opioids

More information

In 2010, approximately 8 million Americans 18 years and older were dependent on alcohol.

In 2010, approximately 8 million Americans 18 years and older were dependent on alcohol. Vivitrol Pilot Study: SEMCA/Treatment Providers Collaborative Efforts with the treatment of Opioid Dependent Clients Hakeem Lumumba, PhD, CAADC SEMCA Scott Schadel, MSW, LMSW, CAADC HEGIRA PROGRAMS, INC.

More information

Medications for Alcohol and Opioid Use Disorders

Medications for Alcohol and Opioid Use Disorders Medications for Alcohol and Opioid Use Disorders Andrew J. Saxon, M.D. Center of Excellence in Substance Abuse Treatment and Education (CESATE) VA Puget Sound Health Care System Alcohol Pharmacotherapy

More information

Guidelines for the Prescribing, Supply and Administration of Methadone and Buprenorphine on Transfer of Care

Guidelines for the Prescribing, Supply and Administration of Methadone and Buprenorphine on Transfer of Care Hull & East Riding Prescribing Committee Guidelines for the Prescribing, Supply and Administration of Methadone and Buprenorphine on Transfer of Care 1. BACKGROUND Patients who are physically dependent

More information

This module reviews the following: Opioid addiction and the brain Descriptions and definitions of opioid agonists,

This module reviews the following: Opioid addiction and the brain Descriptions and definitions of opioid agonists, BUPRENORPHINE TREATMENT: A Training For Multidisciplinary Addiction Professionals Module II Opioids 101 Goals for Module II This module reviews the following: Opioid addiction and the brain Descriptions

More information

Detox Day. RCGP June 13 th 2006. Daphne Rumball Addictions Psychiatrist. Norfolk. Daphne Rumball RCGP Detox Day June 2006 1

Detox Day. RCGP June 13 th 2006. Daphne Rumball Addictions Psychiatrist. Norfolk. Daphne Rumball RCGP Detox Day June 2006 1 Detox Day RCGP June 13 th 2006 Daphne Rumball Addictions Psychiatrist Norfolk Daphne Rumball RCGP Detox Day June 2006 1 Scope of presentation Undertaking detox in the community A review of evidence and

More information

DrugFacts: Treatment Approaches for Drug Addiction

DrugFacts: Treatment Approaches for Drug Addiction DrugFacts: Treatment Approaches for Drug Addiction NOTE: This is a fact sheet covering research findings on effective treatment approaches for drug abuse and addiction. If you are seeking treatment, please

More information

Opiate Abuse and Mental Illness

Opiate Abuse and Mental Illness visited on Page 1 of 5 LEARN MORE (HTTP://WWW.NAMI.ORG/LEARN-MORE) FIND SUPPORT (HTTP://WWW.NAMI.ORG/FIND-SUPPORT) GET INVOLVED (HTTP://WWW.NAMI.ORG/GET-INVOLVED) DONATE (HTTPS://NAMI360.NAMI.ORG/EWEB/DYNAMICPAGE.ASPX?

More information

THE BASICS. Community Based Medically Assisted Alcohol Withdrawal. World Health Organisation 2011. The Issues 5/18/2011. RCGP Conference May 2011

THE BASICS. Community Based Medically Assisted Alcohol Withdrawal. World Health Organisation 2011. The Issues 5/18/2011. RCGP Conference May 2011 RCGP Conference May 2011 Community Based Medically Assisted Alcohol Withdrawal THE BASICS An option for consideration World Health Organisation 2011 Alcohol is the world s third largest risk factor for

More information

Treatment Approaches for Drug Addiction

Treatment Approaches for Drug Addiction Treatment Approaches for Drug Addiction NOTE: This is a fact sheet covering research findings on effective treatment approaches for drug abuse and addiction. If you are seeking treatment, please call the

More information

DEVELOPING MANUFACTURING SUPPLYING. Naltrexone Implants. Manufactured by NalPharm Ltd WWW.NALPHARM.COM

DEVELOPING MANUFACTURING SUPPLYING. Naltrexone Implants. Manufactured by NalPharm Ltd WWW.NALPHARM.COM DEVELOPING MANUFACTURING SUPPLYING Naltrexone Implants Background to Nalpharm NalPharm is a specialist pharmaceutical company supplying proprietary branded medications and generic drugs in the area of

More information

Cessation of methadone maintenance treatment using buprenorphine: transfer from methadone to buprenorphine and subsequent buprenorphine reductions

Cessation of methadone maintenance treatment using buprenorphine: transfer from methadone to buprenorphine and subsequent buprenorphine reductions Drug and Alcohol Dependence 71 (2003) 49/55 www.elsevier.com/locate/drugalcdep Cessation of methadone maintenance treatment using buprenorphine: transfer from methadone to buprenorphine and subsequent

More information

Beyond SBIRT: Integrating Addiction Medicine into Primary Care

Beyond SBIRT: Integrating Addiction Medicine into Primary Care Beyond SBIRT: Integrating Addiction Medicine into Primary Care Community Clinic Association of Los Angeles County 14 th Annual Health Care Symposium March 6, 2015 Keith Heinzerling MD, Karen Lamp MD; Allison

More information

Benzodiazepine Detoxification and Reduction of Long term Use

Benzodiazepine Detoxification and Reduction of Long term Use Benzodiazepine Detoxification and Reduction of Long term Use Malcolm Lader 1 Model of general drug misuse and dependence. Tactical interventional options Social dimension Increasing breaking of social

More information

Review Article. Ultra-rapid opioid detoxification: Current status and controversies

Review Article. Ultra-rapid opioid detoxification: Current status and controversies Review Article www.jpgmonline.com Ultra-rapid opioid detoxification: Current status and controversies Singh J, Basu D Department of Psychiatry, Post Graduate Institute of Medical Education and Research,

More information

Pharmacotherapy for Opioid Addiction: Drugs in Development

Pharmacotherapy for Opioid Addiction: Drugs in Development Pharmacotherapy for Opioid Addiction: Drugs in Development Walter Ling MD UCLA/ISAP Pharmacotherapy for Prescription Opioid Addiction: Implications for Pain Management June 9-10, 2011 Boston, Mass. lwalter@ucla.edu

More information

Drug-Free Strategy in Treatment of Opiate Addiction in Russia

Drug-Free Strategy in Treatment of Opiate Addiction in Russia National Research Center on Addictions Russian Federation Ministry of Health Drug-Free Strategy in Treatment of Opiate Addiction in Russia Stanislav Mokhnachev,, M.D., Ph.D. Head of Drug Addiction Clinical

More information

MEDICAL ASSISTANCE BULLETIN

MEDICAL ASSISTANCE BULLETIN ISSUE DATE September 4, 2015 SUBJECT EFFECTIVE DATE September 9, 2015 MEDICAL ASSISTANCE BULLETIN NUMBER *See below BY Prior Authorization of Opiate Dependence Treatments, Oral Buprenorphine Agents - Pharmacy

More information

BUPRENORPHINE TREATMENT

BUPRENORPHINE TREATMENT BUPRENORPHINE TREATMENT Curriculum Infusion Package (CIP) Based on the Work of Dr. Thomas Freese of the Pacific Southwest ATTC Drug Addiction Treatment Act of 2000 (DATA 2000) Developed by Mountain West

More information

Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department

Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department Drug and Alcohol Dependence 86 (2007) 239 244 Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department M.L. Berg a, U. Idrees b,, R. Ding c, S.A. Nesbit b, H.K. Liang d,

More information

Comprehensive Behavioral Care, Inc. Level of Care Guidelines Substance Abuse Adult

Comprehensive Behavioral Care, Inc. Level of Care Guidelines Substance Abuse Adult Comprehensive ehavioral Care, Inc. delivery system that does not include sufficient alternatives to a particular LOC and a particular patient. Therefore, CompCare considers at least the following factors

More information

Pain Medication Taper Regimen Time frame to taper off 30-60 days

Pain Medication Taper Regimen Time frame to taper off 30-60 days Pain Medication Taper Regimen Time frame to taper off 30-60 days Medication to taper Taper Regimen Comments Methadone Taper by no more than 25% Morphine Taper by no more than 25% Tramadol Taper by no more

More information

Section Editor Andrew J Saxon, MD

Section Editor Andrew J Saxon, MD Official reprint from UpToDate www.uptodate.com 2015 UpToDate Pharmacotherapy for opioid use disorder Author Eric Strain, MD Section Editor Andrew J Saxon, MD Deputy Editor Richard Hermann, MD All topics

More information

Guidelines for Titration onto Buprenorphine in Opioid Dependence

Guidelines for Titration onto Buprenorphine in Opioid Dependence NHS Fife Community Health Partnership Addiction Services Guidelines for Titration onto Buprenorphine in Opioid Dependence Intranet Procedure No. A7 Author Dr L. Cockayne Copy No 1 Reviewer Lead Clinician

More information

This controlled document shall not be copied in part or whole without the express permission of the author or the author s representative.

This controlled document shall not be copied in part or whole without the express permission of the author or the author s representative. This document can be made available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on 01224 551116 or 01224 552245. This controlled document

More information

UNIT VIII NARCOTIC ANALGESIA

UNIT VIII NARCOTIC ANALGESIA UNIT VIII NARCOTIC ANALGESIA Objective Review the definitions of Analgesic, Narcotic and Antagonistic. List characteristics of Opioid analgesics in terms of mechanism of action, indications for use and

More information

MEDICAL TRIBUNAL OF NSW REASONS. Matter no: 40033 of 2012

MEDICAL TRIBUNAL OF NSW REASONS. Matter no: 40033 of 2012 MEDICAL TRIBUNAL OF NSW REASONS Deputy Chairperson: Tribunal Members: Judge A. Balla Dr E Kok DrGDore Dr A Glass, PhD Matter no: 40033 of 2012 Applicant: Respondent: Counsel for the Applicant: Counsel

More information

What is Addiction and How Do We Treat It? Roger D. Weiss, M.D. Professor of Psychiatry, Harvard Medical School Clinical Director, Alcohol and Drug

What is Addiction and How Do We Treat It? Roger D. Weiss, M.D. Professor of Psychiatry, Harvard Medical School Clinical Director, Alcohol and Drug What is Addiction and How Do We Treat It? Roger D. Weiss, M.D. Professor of Psychiatry, Harvard Medical School Clinical Director, Alcohol and Drug Abuse Treatment Program, McLean Hospital, Belmont, MA

More information

Procedure for Community Detoxification using Prescribed Lofexidine with or without Naltrexone

Procedure for Community Detoxification using Prescribed Lofexidine with or without Naltrexone NHS Fife Community Health Partnerships Subject Title Addiction Services Procedure for Community Detoxification using Prescribed Lofexidine with or without Naltrexone Intranet Procedure No. A2 Author Dr

More information