Author: Alex Thompson

Addressing unmet needs in opiate dependence: supporting detoxification and advances in relapse prevention BJPsych Advances

As we start to recover from this pandemic, there will be an inevitable backlog of issues that will need to be addressed for this population and the need for better detoxes and relapse prevention will be even more pressing. After discussion with you, your health care provider may recommend medicine as part of your treatment for opioid addiction. These medicines can reduce your craving for opioids and may help you avoid relapse. Medicine treatment options for opioid addiction may include buprenorphine, methadone, naltrexone, and a combination of buprenorphine and naloxone. Medications used in the treatment of opioid addiction support a person’s recovery by helping to normalize brain chemistry, relieving cravings, and in some cases preventing withdrawal symptoms.

Also, be sure to ask if drugs other than opioids are available or if other types of treatment can be used instead. Opioids are most addictive when you take them in a way other than how they were prescribed — for example, crushing a pill so that it can be snorted or injected. This life-threatening drug misuse is even more dangerous if the pill is effective for a longer period of time.

Thus, an individual can be dependent on a drug but not necessarily ‘addicted’, which is a complex behaviour including difficulty in controlling use and continuing despite harm. The latest changes to the DSM’s diagnostic criteria for substance dependence (DSM-5; American Psychiatric Association 2013) reflect this (Box 2). Tolerance in opioid addiction commonly manifests itself as users requiring greater doses to produce the desired pleasant euphoric effects. Although this occurs rapidly, leading to reinforcement and increase of dosage and frequency of drug taking, tolerance for other effects of opioids, such as nausea and respiratory depression, can develop at different rates.

Opioid Agonists and Partial Agonists (Maintenance Medications)

There is a lack of studies investigating the effects of motivational interviewing in opiate dependence. This analysis did not find a significant effect immediately post-treatment (Sayegh Reference Sayegh, Huey and Zara2017). Diagnosing drug addiction (substance use disorder) requires a thorough evaluation and often includes an assessment by a psychiatrist, a psychologist, or a licensed alcohol and drug counselor. Blood, urine or other lab tests are used to assess drug use, but they’re not a diagnostic test for addiction.

Worse yet, relapse can lead to a life-threatening overdose due to reduced tolerance to opioids. While this is one of the reasons why opioid detox is dangerous, it isn’t the only one; it can also lead to adverse events like cardiac arrest, worsening of mental health problems, and even death. Opioid detox cannot treat opioid dependence and addiction because it fails to address their root cause—the opioid-induced imbalance in brain chemistry.

Steps to prevent opioid use disorder

Even at high doses buprenorphine results in less euphoria, sedation, respiratory depression and fatal overdose than methadone. Buprenorphine has high affinity at the MOR, so in the presence of other opioids it will antagonise their effects. Thus, if buprenorphine is taken when someone has an opioid agonist (e.g. heroin) in their system, withdrawal is precipitated. Conversely, in someone maintained on buprenorphine, MOR are occupied so that on-top heroin use results in no effect, making such illicit use less likely.

1. The misuse of opioids — legal, illegal, stolen or shared — is the reason 90 people die in the U.S. every day on average, according to the American Society of Anesthesiologists.
2. Opioid dependence refers to the physical dependence on these medications that anyone—including those who carefully follow their doctor’s directions—will develop if they take them long enough.
3. Lofexidine has been available for decades in the UK, but it received a licence for use in the USA only in 2018.
4. To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies.

A report from the Advisory Council on the Misuse of Drugs (ACMD) in 2015 cited several factors that contribute to this phenomenon, including prescriber factors such as reluctance due to moral reasons and fear of diversion. The dangers of diversion are particularly prominent for higher OST doses, where diversion could be fatal, and supervision of consumption is often employed to minimise diversion risk. Conversely, patient factors include concerns about side-effects of high doses, concern about never being able to ‘come off’, and being able to continue to use heroin on top of the OST dose. The report also suggests that slow reduction regimes may in fact be long-term underdosing, leading to on-top heroin use and longer periods of suboptimal OST. Naltrexone is an opioid antagonist, which means that it works by blocking the activation of opioid receptors. Instead of controlling withdrawal and cravings, it treats opioid use disorder by preventing any opioid drug from producing rewarding effects such as euphoria.

Opioid withdrawal symptoms can be tough to bear; many users continue taking opioids just to alleviate their suffering. Besides hindering endorphin production, repeated opioid exposure also causes an increase in the production of opioid receptors, leading to tolerance. This, coupled with the fact that there’s a lack of evidence to prove the benefits of long-term opioid use, explains why it is generally not recommended to take these medications for a prolonged period. ICD-11 criteria relating to substance dependence largely remain unchanged from the previous version, separating ‘harmful use’ from ‘dependence’. Conversely, DSM-5 has altered its nomenclature from ‘addiction’ and ‘dependence’ to ‘substance use disorder’, in part to mitigate the confusion surrounding these terms.

Mayo Clinic Press

Development of physical dependence from regular, chronic use of opioids (including opioid analgesics) will also manifest itself as a withdrawal syndrome in the absence of opioids. Of particular relevance to treatment of opioid withdrawal is the ‘noradrenergic storm’. When a circulating opioid is then removed, cAMP levels increase to far above normal levels. Functionally this occurs in the main noradrenaline-containing nucleus in the brain, the locus ceruleus, resulting in an increase in circulating noradrenaline (Nestler Reference Nestler2004).

If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account.Find out more about saving content to Google Drive. To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account.Find out more about saving content to Dropbox. SAMHSA’s National Helpline is a great resource to share with someone who may have a substance use disorder. You’ll soon start receiving the latest Mayo Clinic health information you requested in your inbox.

While other opioid treatment programs often take months, if not years, to complete and still don’t guarantee long-term results, opioid detox is often marketed as a quick and easy fix for opioid addiction. There are many ways to treat opioid addiction and dependence, but not all of them are equally effective. The mu-opioid receptor (MOR) is found in various brain regions involved in the reward circuitry, including the ventral tegmental area and ventral striatum.

ANR Treatment: A Revolutionary Opioid Dependence Treatment

‘Substance use disorder’ is referred to as a continuum rather than distinct categories of ‘abuse’ and ‘dependence’. Opioid addiction treatment can vary depending the patient’s individual needs, occur in a variety of settings, take many different forms, and last for varying lengths of time. Even after you’ve completed initial treatment, ongoing treatment and support can help prevent a relapse. Follow-up care can include periodic appointments with your counselor, continuing in a self-help program or attending a regular group session. For diagnosis of a substance use disorder, most mental health professionals use criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Despite record-breaking numbers of opiate related deaths in the UK in 2019, pharmacological management of opiate dependence has evolved little since the advent of methadone in 1965. Along with harm minimisation and psychosocial interventions, the mainstay of pharmacological treatment remains opioid substitution therapy (OST) using methadone or buprenorphine, with many patients receiving OST for many years. Even with these treatments, opiate users continue to face mortality risks 12 times higher than the general population, and emerging evidence suggests that individuals who remain on long-term OST present with a range of physical and cognitive impairments. Concern about risk of fatal relapse to opiate use is also a powerful message to encourage continued use of OST. The opioid antagonist naltrexone is the only medication for relapse prevention licensed in the UK and it is based on its ability to block access of consumed opiates to the opioid receptors. Despite the availability of naltrexone for relapse prevention, poor adherence is commonplace, with most dependent opiate users returning to their drug use.