The management of opioid addiction or dependence involves both diagnosing as well as treating the condition. Treatment may be ongoing on a long term or even lifelong basis for some individuals.
The steps taken to diagnosis and treat opioid addiction include:
Investigations
Urine is commonly analyzed first for the presence of opioids and its metabolites. Various opioid compounds are present in the urine for different lengths of time. For example, heroin may only remain in urine for up to 2 days whereas methadone may remain detectable for over a week and up to 10 days.
Saliva is also tested for evidence of recent drug use and may detect heroin if it has been taken within the last 24 to 48 hours.
Management of acute opioid intoxication or overdose
Mild-to-moderate acute opioid intoxication may not require any specific treatment other than close observation and monitoring.
Severe opioid overdose is a medical emergency and may be life threatening if not treated promptly. Overdose often causes severe depression of the respiratory drive which may be treated using an opioid antagonist called naloxone.
Cessation of opioids
Stopping opioid use can lead to withdrawal symptoms which need systematic treatment. Often a long-term treatment plan or program is necessary for weaning an addict off the opioid. Medications that may be administered include:
- Clonidine - This is a blood pressure lowering agent that has a wide range of uses. It is non-narcotic and is a centrally acting alpha-2 adrenergic agonist that reduces the symptoms caused by withdrawal of opioids. For opioid withdrawal, clonidine is typically dosed at 0.1 mg to 0.3 mg orally up to every 6 hours.
- Clonidine may be used in combination with an opioid antagonist called naltrexone. Initial treatment is begun with clonidine to avoid some of the abrupt withdrawal symptoms that may occur with naltrexone. Naltrexone is an antagonist at the mu receptor and to some extent the kappa and delta receptors. When given in combination with clonidine, naltrexone is usually given between 50 mg and 100 mg daily or up to three times a week.
Substitution of opioids
One of the major treatment approaches to opioid addiction is the substitution of more potent and more addictive opioids such as heroin, with clinically-used opioids such as methadone or buprenorphine. Among people who have a history of dependence lasting more than 1 year, substitution therapy is usually the best choice.
Methadone was introduced as a treatment of opioid addiction in the 1960's and buprenorphine much later in 2000. It was in 1968 that Drs Marie Nyswander and Vincent Dole found that use of once daily methadone could reduce the symptoms of opioid withdrawal and the cravings associated with stopping the more potent opioids. By 1971, the substitution therapy was widely used in the methadone maintenance treatment program.
Methadone is an opioid receptor agonist at the mu-receptor and an antagonist at the N-methyl-D-aspartate receptor. Buprenorphine is a partial mu-receptor agonist and also acts as an antagonist at the kappa receptor.
Psychotherapy
Counselling and psychiatric assistance may help a person curb any cravings and maintain a drug-free existence in the long term. Such therapy may also be useful in treating any other psychiatric conditions such as depression that may manifest as a result of opioid dependence. Attempts are also made to rehabilitate the person into family life and and society.
Further Reading
Obese patients can manage pain without opioids after bariatric surgery