• Summary
• Introduction
• Reasons for detoxing
• Blind or open reductions?
• Setting the appropriate rate of detox
• Detox regime suggestions
• Anxiety
• Abstinence phobia
• Alternatives to methadone in detoxification
• Methadone v heroin in detoxification
• Follow up/relapse prevention

Summary

• The physical process of detoxification is, in itself, relatively easy to achieve.

• Long-term abstinence from opiate use is much harder to achieve.

• Most opiate users will undergo detoxification many times before they achieve lasting periods opiate free.

• Prescribed medication to assist in these detoxes will probably be a feature on more than one occasion.

• Lofexidine is a useful non-opiate treatment for both community and in-patient rapid detoxification.

• It is important that services respond to the requests for help in a therapeutic way that reduces drug-related harm and helps the client move on and learn from their experiences.

• Drug users who become abstinent are vulnerable to relapse.

• Drug services should offer full support for at least 6 months following detox.

Introduction
Methadone detoxification is a complex area dealt with in various sections throughout this book.

This section deals with the practical issues around prescribing and the rate of detox, the anxieties for clients about detox and the alternatives to methadone in detox.

This section should be read in conjunction with:

• Section 2 - where there is a discussion of the research into methadone detoxification
• Section 4 - where withdrawal symptoms are discussed
• Section 7 - where there is discussion of the different detox durations and their indications and contra-indications
• Section 11 - where there is discussion of detoxification which does not end in lasting abstinence.

People reducing from methadone are often anxious and afraid of the withdrawal syndrome and relapse.

Relapse following detox is an often neglected area because drug services and drug users tend to concentrate on the withdrawal syndrome and process of detoxification.

Effective follow up is vital in ensuring that detoxification is more than a reducing dose of methadone mirrored by a concurrent rise in heroin (or other depressant drug) use or a prelude to a short period of abstinence followed by relapse that the prescriber is unaware of.

Information for clients on the issues around detoxification and residential rehabilitation is available in the Detox Handbook and the Rehab Handbook - also available from ISDD (address on back cover).

Reasons for detoxing
In an ideal world people would detox from a stabilising dose of methadone or illicit drugs when they, and their prescriber, agreed that they were ready and able to do so without significant risk of early relapse. However people may want to detox when either they or their prescriber do not feel they are ready because:

• Service prescribing policy dictates the regime on offer
• They have a new job
• They are moving to a new area
• Of changes in their relationship
• Attitudes of staff involved in methadone prescribing
• Unrealistic staff beliefs about client's ability to achieve abstinence
• Unrealistic client beliefs about their ability to achieve abstinence
• Stigma associated with having a methadone prescription
• Dislike of practical aspects of a regime, such as the collection frequency
• Change of drug of choice e.g. methadone to benzodiazepines or alcohol
• Exclusion from a prescribing programme
• Imminent or actual prison sentence.

These are discussed below.

Attitudes of staff
Opiate users are sensitive to the attitudes of the staff they come into contact with and sometimes choose not to seek, or to terminate treatment because of the attitudes and behaviour of staff.

This can probably be best avoided by offering services that are:

• Client centred
• Empowering
• Flexible in their treatment approaches
• Not seen to subscribe rigidly to any duration of methadone treatment
• Non-judgmental and respectful
• Staffed by people who are well trained and receive good supervision.

Following these principles also means that, having discussed the options, if a client decides to detoxify against advice the staff should still offer their full support and encouragement during and after the detox. They should also endeavour to discuss possible outcomes in a way that does not set the client up to fail but allows the making of contingency plans that can be brought into play if the detox does not work.

Unrealistic staff beliefs about a client's ability to detox
It is easy for workers to fall into the trap of prematurely believing that people can achieve abstinence and encourage the client to detox. Often the client will continue down this road because they do not want to upset the worker and this can continue afterwards, with the client not wishing to re-refer themselves to a prescribing service for fear of admonishment from, or upsetting, the people who helped them before.

Cushman and Dole⁸⁷ found that of a group of methadone maintenance clients who were assessed as 'rehabilitated' and detoxed with the anticipation of success, some asked to be returned to maintenance during the detox and 25% returned to maintenance after detox (mainly because of protracted withdrawals).

Therefore support, encouragement and optimism should always be tempered by continual reassessment and meaningful negotiation.

Unrealistic client beliefs about their ability to detox
Clients too can be unrealistically optimistic about their ability to get off opiates. Often people will present after many years of heavy opiate use, adamant that in a few weeks they will be able to get themselves together and detox successfully.⁸⁸

This belief sometimes stems from concentrating on the physical aspects of opiate withdrawal. If past experience of relapse during or after opiate detox has been that the withdrawal symptoms were the main factor causing relapse, this can reinforce the belief that if the physical symptoms of withdrawal can be reduced to tolerable levels by a methadone detox, abstinence will be easily achieved.

Another factor can be the flawed but understandable and apparently logical conclusion that 'if all my problems are heroin-related then if I give up heroin all my problems will go away'. The experience of many is that the compulsive behavioural aspects of their drug taking and the social and emotional difficulties that they experience once opiate-free add a previously ignored and difficult-to-overcome dimension to their drug use.

Stigma associated with having a methadone prescription
Many people on a maintenance methadone prescribing programme say 'the act of having to take an opiate every day is a reminder that I'm a junkie'.

For the relatives and friends of people on methadone it can be perceived as being 'as bad as heroin' - regardless of any associated lifestyle improvements that have been achieved. Indeed associated improvements often serve only to increase the pressure on the person to detox as the perception is that they do not need the methadone anymore.

Heroin users are often dismissive of those on methadone and street myths of the terrible long-term health consequences of methadone treatment still abound. So the person receiving methadone often feels stigmatised from all sides.

Heroin users who feel the need to seek help for the first time also feel this and may request a methadone detox so that they can rationalise their request as one for a short-lived intervention that does not involve long-term methadone treatment.

Dislike of practical aspects of a regime, such as the collection frequency
Avoidance of longer-term treatment may also include factors such as a desire not to have to:

• Collect methadone daily from a drug service or pharmacy.
• Attend a drug service on a regular basis
• Engage in a counselling relationship
• See other drug users when collecting the prescription and/or methadone

It is important for the worker involved to have an awareness of these issues if they are factors in a request for methadone detoxification.

Change of drug of choice
Sometimes poly drug users change their drug of choice in a cyclical way from, say, heroin to benzodiazepines to alcohol to amphetamines and back to heroin; or simply switch from heroin to, say, alcohol and back again.

They may ask for a detox at the end of the opiate part of the cycle - either as a new referral as a heroin user or following a period on methadone. In these cases treatment may or may not be appropriate, but if commenced should be carefully monitored.

Clients going to prison
Clients who have a prison sentence coming up present drug services with a dilemma. On the one hand premature detox may lead to relapse with risk behaviour prior to prison. On the other hand arriving at a prison where detox facilities are poor or non-existent in full methadone withdrawal is likely to result in illicit heroin use. The sharing of injecting equipment in prison is much more prevalent than in the community. The best that can be done is to:

• Offer as much support as possible
• Help them make informed choices
• Inform them of the risks of intravenous drug use in prison
• Appropriately influence the pre-sentence report.

Blind or open reductions?
There is no evidence to suggest that knowing or not knowing the frequency or size of dose reductions is more effective in helping people detox using methadone.

The answer for most people who attend prescribing and dispensing services that are flexible enough to offer both, is to consider the pros and cons of each approach in conjunction with the prescribing staff, and to make an informed decision for themselves as to which is the most appropriate regime. Generally a key factor is the level of control that a person feels they have over their lives. Anyone who feels in control is unlikely to opt for blind dose reductions.

The arguments for and against blind and open reductions are set out below.

Setting the appropriate rate of detox
Almost everyone undergoing methadone detoxification will experience withdrawal symptoms, and for many these will be serious enough to be a major contributing factor in either relapse to heroin use or a request for methadone maintenance - even if all other preconditions for a successful detox are in place.⁸⁷

For people detoxing following a period on methadone maintenance, faster detoxes are associated with higher drop-out rates and slower detoxes are associated with lower drop-out rates.⁸⁹

In general detoxes consist of gradual reductions of 5mg or 10mg in the daily dose to a given level, usually 20-30mg (depending on the starting dose and the client), and then become more gradual, either in terms of time between reductions and/or size of daily dose reduction.

Negotiation between worker and client is an important component of any detoxification. A negotiated detoxification in which the client is able to take responsibility for coping with the dose reductions is likely to reduce the risk of concurrent illicit opiate use and be a better foundation for continued abstinence afterwards.

Prescribers without specialist experience who agree to a short-term programme without support from a specialist service should seek support if their patient is unable to detox successfully at the agreed rate.

Detox regime suggestions

Long-term detox regimes are seldom the optimum treatment option, to read an additional piece on long-term detox written for this online edition of the book, please click here.

All the regimes below are for methadone mixture 1mg/1mL. All detox regimes are a plan only and should be subject to regular, i.e. weekly or fortnightly, review against the treatment aims.

The definitions, indications and contra-indications for each of the regimes below are given in Section 7 - Treatment aims and choices. It is important that detox regimes are only entered into with clear treatment aims and following a thorough assessment that has established that these aims are achievable.

The very low doses (i.e. less than 5mg) suggested in the following regimes are of little physiological value as they are unlikely to make much difference to the level of physical withdrawal. However withdrawal symptoms can also be aggravated by anxiety and where low dose prescribing at the end of a detox reduces anxiety it is likely to reduce subjectively experienced withdrawals.

Where a client has high levels of anxiety about making the final reductions they are often afraid of being drug free and of the changes this will bring. It is therefore important that low dose prescribing is coupled with counselling.

Short-term detoxification: decreasing doses over one month or less Two week detoxification regime

• 20mg for 3 days
• 15mg for 4 days
• 10mg for 3 days
• 5mg for 4 days

This regime has the advantage that it is easy to prescribe as there is a dose drop at the end of each week.

An alternative starting slightly higher could be:

• 25mg for 3 days
• 20mg for 3 days
• 15mg for 3 days
• 10mg for 3 days
• 5mg for 2 days

For people who need more methadone to stabilise or who are detoxing from an existing methadone prescription there are two main choices. Either reduce the dose prior to the final detox or reduce the dose by 25%-50% each day until 20mg is reached and then complete the programme as above. However it must be recognised that these large early reductions will probably result in intense withdrawal symptoms.

If required, 'holding' on a given dose on one or two occasions during the detox may increase the client's sense of control and decrease their anxiety. Delays in the rate of reduction should usually be accompanied by an increase in psychological support.

Longer-term detoxification: decreasing doses over 1-6 months

1 month detoxification regime

From a starting dose of 40mg:

• 40mg for 4 days
• 35mg for 3 days
• 30mg for 4 days
• 25mg for 3 days
• 20mg for 4 days
• 15mg for 3 days
• 10mg for 4 days
• 5mg for 3 days

From a starting dose of 25mg:

• 25 mg for 4 days
• 20mg for 3 days
• 15mg for 4 days
• 10mg for 3 days
• 8mg for 4 days
• 6mg for 3 days
• 4mg for 4 days
• 2mg for 3 days

4 month detoxification regime
Following initial stabilisation, and a period in which the client remains heroin free, the daily dose can be reduced by 5mg or 10mg every week or fortnight until 30mg is reached.

The rate of reduction in the daily dose is then reduced to 5mg every week or fortnight until 10-15mg is reached. At this point daily dose reductions can be reduced to 2 or 2.5mg every week or fortnight.

A typical 4 month regime using these principles from a starting dose of 45mg would be:

• 45mg for 14 days
• 35mg for 14 days
  
  
• 30mg for 14 days
• 25mg for 14 days
  
  
• 20mg for 14 days
• 15mg for 14 days
  
  
• 10mg for 14 days
• 7mg for 14 days

6 month detoxification regime
A 6 month detox regime using the same principles as the 1-5 month detox, from a start of 60mg might be:

• 60mg for 14 days
• 50mg for 14 days
  
  
• 40mg for 14 days
• 30mg for 14 days
  
  
• 25mg for 14 days
• 20mg for 14 days
  
  
• 15mg for 14 days
• 10mg for 14 days
  
  
• 8mg for 14 days
• 6mg for 14 days
  
  
• 4mg for 14 days
• 2mg for 14 days
  
  

Detoxification following exclusion from a methadone prescribing programme
Sometimes methadone prescriptions are stopped. The reasons for doing this are discussed in Section 10: Practical issues in methadone prescribing - Terminating treatment.

The client should be aware of exactly what the rate of detox will be before the prescription is terminated. Abrupt cessation of opiates is not fatal in people who are otherwise healthy. The rate of reduction therefore usually seeks to strike a balance between continuance of the prescribing programme under a new guise, and a rate of reduction which gives the individual little chance of achieving abstinence if they want to.

A regime such as the following is commonly used:

• 10mg reduction in the daily dose every day until the patient is receiving 30mgs daily

and then:

• 5mg reduction in the daily dose each day with 2 days on 5mg at the end.

However any of the above regimes could be employed.

Anxiety
Client expectations of anxiety are one of the best indicators of the intensity of withdrawal symptoms and there can be little doubt that the two are closely linked.

As with all anxiety-provoking situations, levels of anxiety during and after methadone detoxification can be reduced through information being given to the client about what they can expect to happen and why it is happening, and the opportunity being given to discuss the issues that are raised.

Emotions such as anger and depression can trigger withdrawal symptoms in people who are stabilised on methadone - this is known as 'pseudo withdrawal syndrome'. If clients become more aware of these feelings during a detox then this too will increase the severity of their withdrawal symptoms. Counselling during and after the detox can help deal with these emotions and reduce the physical consequences.

Abstinence phobia
S M Hall in 1979 described abstinence phobia as an exaggerated response to comparatively mild withdrawal symptoms.⁹⁰

Indeed many clients become very anxious as soon as dose reductions begin and feel unable to continue with the detoxification. Hall suggested that previous actual or observed traumatic experience of withdrawal symptoms may be the cause of this fear. Unfortunately her attempts to use standard cognitive behavioural therapy in a controlled trial - which has been shown to be effective in other anxiety disorders - were unsuccessful.

This being the case, choices for clients who demonstrate high levels of anxiety during detox are limited as they are unlikely to achieve abstinence without considerable support. Slowing the rate of reduction and increasing support is the first line response. Following this in-patient detoxification or residential rehabilitation might be options.

If the anxiety cannot be resolved, and relapse is the outcome of all attempts at detox, the most appropriate response may be methadone maintenance.

Alternatives to methadone in detoxification

Clonidine
This is similar in its action to lofexidine (see below), the major difference being its more powerful hypotensive action which contra-indicates its use in anything other than an in-patient setting. Clonidine has never had a product licence for opiate detoxification.

Lofexidine (BritLofex)
Lofexidine hydrochloride is now fully licensed in the UK for management of the symptoms caused by withdrawal. Lofexidine is not an opiate and does not stimulate opiate receptors and therefore does not have the psychoactive effect nor the dependency potential of opiates.

It works by inhibiting the release of noradrenaline. Noradrenaline is a key chemical transmitter that acts on the nervous system, the action of which has been suppressed by opiates: see Section 4: The physiology and pharmacology of methadone.

As lofexidine is not an opiate, increasing the dose too quickly, or beyond the recommended maximum, will not necessarily reduce withdrawal symptoms but it will increase the risk of side effects such as hypotension (low blood pressure). This should be made very clear to patients who are self administering their lofexidine tablets.

The safety of lofexidine in pregnancy has not yet been established.

Lofexidine is unlikely to:

• Completely eliminate withdrawal symptoms (the extent to which it reduces withdrawal symptoms varies)
• Greatly affect the insomnia associated with opiate withdrawal
• Stop cravings for opiates
• Reduce anxiety
• Be effective if used in the absence of careful assessment and support during and after treatment.

The effect of these factors can be reduced by:

• Giving the client full information about what to expect
• Using low-dose prescribed night sedation for a defined period (lofexidine may potentiate the action of anxiolytics and hypnotics)
• Offering support and counselling during and after the detox.

Side effects
Hypotension (low blood pressure) is the principle possible side effect that can occur during treatment with lofexidine. Although this could prohibit its use for some clients and may result in discontinuation of treatment in others, in practice there is rarely a clinically significant reduction in blood pressure.

Blood pressure should be monitored, especially while the dose is increasing. For in-patients if the standing systolic BP has dropped by more than 30 mmHg (and is associated with symptoms of dizziness and light-headedness or over-sedation) the next dose of lofexidine should be withheld until the systolic BP is less than 30mmHg below the baseline.

Sedation is more likely to occur in clients concurrently prescribed (or taking) benzodiazepines and/or other central nervous system depressants.

Lofexidine is safe for community use in patients who are:

• Able to control their use of the drug
• Unlikely to use illicit drugs concurrently
• Willing to comply with the regime
• In regular contact with the prescriber/drug worker.

A typical 10 day out-patient lofexidine regime
Reduce the methadone dose to 15mg daily and ask the patient to take their last dose in the evening.

The following morning (detox day 1) begin the following regime:

Notes:

• The action of lofexidine is reduced by tricyclic antidepressants and they should not, therefore, be prescribed concurrently.
• Patients may determine their own dose, titrated against withdrawal symptoms, up to the maximum doses shown.
• Blood pressure and pulse should be monitored regularly, especially while the dose is increasing.
• The maximum dose phase i.e. 'Day 5' may be continued for up to 6 days prior to beginning the 'Day 6-10' reduction regime if withdrawals remain severe or if there has been additional illicit drug use.

The patient must be told:

• To omit or take less than the maximum dose if giddiness is a problem
• That once the maximum dose is reached taking more tablets will only increase the side effects and will not further diminish the withdrawal symptoms
• That the worst withdrawal symptoms will be experienced on days 1-5
• That there may be an immediate drop in tolerance to opiates - so if they relapse, the risk of overdose will be high.

Dihydrocodeine
In an attempt to reduce the severity of withdrawal symptoms some services switch detoxifying clients from methadone to dihydrocodeine for the final part of the process - usually when the daily methadone dose reaches around 15mg.

The rationale for this is that dihydrocodeine is:

• A shorter-acting drug that may interfere with natural endorphin production less than methadone, thus reducing the severity of long-term withdrawals
• A relatively weak opiate (30mg of dihydrocodeine = 3mg of methadone)
• Easy to reduce slowly without practical difficulties, especially if the 10mg/5mL elixir is used.

There have been no controlled trials comparing subjective experience of withdrawals when detoxing on methadone, heroin or dihydrocodeine, but some clinicians have found the switch helpful, particularly if the anxiety of withdrawal is focused on the problems of coming off methadone.

However the treatment can have drawbacks. The experience of a 'high' on dihydrocodeine can be greater than with methadone and thus clients can attempt unsustainable methadone dose reductions in pursuit of the 'reward' of a 'better drug'.

Switching drug can also detract from the other psychological causes of withdrawal symptoms, neglect of which is unlikely to be therapeutic.

The product licence for dihydrocodeine does not include treatment of opiate dependence.

Methadone v heroin in detoxification
There is a commonly held belief amongst drug users that the withdrawal symptoms are worse and more prolonged when coming off methadone than heroin.

Given that methadone is a longer-acting drug this is probably true. However the experience of withdrawal is probably exacerbated by factors which are different with regard to most methadone detoxes as opposed to most illicit heroin detoxes.

Most illicit heroin withdrawal symptoms are:

• Part of a fluctuating drug-using pattern and associated with shortages of heroin
• Result in only a few days' abstinence
• Self-medicated, to some extent, with benzodiazepines, alcohol or other drugs
• Not part of a planned attempt to become drug free.

Most methadone withdrawal symptoms are:

• A planned part of a clear intention to become drug free
• At the end of a planned detox with an intention to give up drug use
• Experienced without the relieving effects of concurrent drug use.

These factors probably all increase the stress associated with methadone dose reductions and serve to increase the subjective experience of withdrawal symptoms. Discussion of these issues with the client will probably serve to reduce the severity of the withdrawal experience.

Follow up/relapse prevention
People who have been using opiates for some time and who detoxify using methadone often benefit from support and assistance for some time afterwards. Plans and support mechanisms for the period after the detox should be in place before it commences.

Risk of relapse is always high as there are many potential causes of relapse including:

• Protracted withdrawal symptoms
• Insomnia
• Environmental cues
• Contact with current users
• Stress
• Anxiety
• Low self esteem
• Depression.

The person who has succeeded in getting off opiates will need help to resist these cues to relapse. Often clients are reluctant to return to prescribing services for follow-up support and there are often few services for those that do.

Support that would help and could be provided by drug services includes:

• 'Coming off/staying off' therapeutic groups
• Relapse prevention training
• Individual counselling
• Self help groups
• Life skills instruction, assertiveness, etc.
• Naltrexone treatment.

Support that could be suggested/facilitated by drug services includes:

• Careers advice
• Further education
• Narcotics Anonymous meetings
• Vocational training.