Drug Detoxification revisited

1. Drug Detoxification revisited Dr Lucy Cockayne Consultant Psychiatrist NHS Lanarkshire

2. Drug Detoxification Revisited Why detox and why NOT to detox? When to detox. How to detox. – the old and the new. What is a successful detox?

3. Choosing the right detox “there are a multitude of treatment approaches to choose from: outpatient, inpatient, 12-step, group therapy, and the list goes on.”

5. Who chooses? “all too often the detoxification process is ‘prescriber/cost/locality’ centred rather than client centred…. Directed to the treatment prescribing services’ preferred modal, irrespective of whether it is the most appropriate for that individual” T.S.Johnson, Addiction Biology 2003

6. Current situation in Scotland – a personal view Postcode lottery Little choice in detoxification options Patchy post detox support User suspicion of social service support – a reluctance to be referred.

7. Opiate detox – the options Broadly three types of detox: Tapering eg methadone reduction Transitional/substitution eg subutex/lofexidine Rapid opiate withdrawal using naltrexone

8. Ultra- rapid opiate detox 3 decades of experience Aim is to increase compfort during withdrawal Little NHS use currently Recent moves from simply detox to NIMROD- i.e.induction onto naltrexone

9. From UROD to NIMROD Various methods: varying from Using anaesthesia (UROD) Takes as little as 4 hours Risks of anaesthesia (some deaths) Asturian technique 6-12 hours Using sedation and early naltrexone challenge 5 day detox Variety of sedatives and side effect medications “test doses” of naltrexone followed by regular oral naltrexone Up to 98% opiate free at the end of the procedure UROD – has been used extensively and very successfullt throughout the owrld Risk/benefit needs to be considered carefully Individuals using it often at “last resort” with little potential for much quality of life and low life expectancy – may be acceptable risk?? UROD – has been used extensively and very successfullt throughout the owrld Risk/benefit needs to be considered carefully Individuals using it often at “last resort” with little potential for much quality of life and low life expectancy – may be acceptable risk??

10. Subutex – a difference in pharmacology

11. However, patient preference important Clients are wary of the change over period from methadone- some see it as a “mini detox”However, patient preference important Clients are wary of the change over period from methadone- some see it as a “mini detox”

12. After detox….. No matter what detox, the risks of relapse are similar – about 90% in first 12 months. Few engage with post detox support… but here is one: Maintenance with ANTAGONISTS – ie naltrexone – worth a second look? I’ve asked one of my patients to share a little of her experience of detox. Would you like to introduce yourserf? Thank you for coming along. It’s not easy to talk to a big audience like this, we really appreciate your willingness to be here. You’ve done two detoxes this year? What was the Subutex detox like? Tell us about the 5-day detox… You are interested in naltrexone implants… what draws you to them? What support are you getting now? What are your hopes for the future? Thank you for coming along.I’ve asked one of my patients to share a little of her experience of detox. Would you like to introduce yourserf? Thank you for coming along. It’s not easy to talk to a big audience like this, we really appreciate your willingness to be here. You’ve done two detoxes this year? What was the Subutex detox like? Tell us about the 5-day detox… You are interested in naltrexone implants… what draws you to them? What support are you getting now? What are your hopes for the future? Thank you for coming along.

15. Improving compliance Entrusting administration to a relative or carer (Anton, 1981) Contingency contracting (Preston, 1999) Naltrexone administered by probation officers (Cornish, 1997)

23. Taking implants forward in the UK As unlicenced only appropriate in a research setting Several trials being proposed – but problems with indemnity… WATCH THIS SPACE….