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How to manage opiate dependence and withdrawal

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In 1998, in response to the escalation in problematic drug use, the government launched a 10-year drug strategy entitled Tackling Drugs to Build a Better Britain (Government Publication, 1998). 

Abstract

VOL: 101, ISSUE: 37, PAGE NO: 30

Gabrielle Tracey McClelland, MSc, RMN, RGN, diploma in nursing studies, postgraduate diploma in research methods for social sciences, is practitioner/lecturer in mental health nursing, University of Bradford

The strategy has four key areas:

- Young people;

- Crime;

- Communities;

- Treatment.

The government’s drug strategy has prioritised the use of class A drugs in response to an escalation in use (Home Office, 2002). The National Treatment Agency for Substance Misuse was launched in 2001 to oversee the process of establishing and disseminating national standards for the commissioning, delivery and monitoring of drug treatment services (NTA, 2001). Action teams were also established to compile local drug plans.

What are opiates?

Opiates are a group of drugs derived from the opiate poppy Papaver somniferum. They all have similar effects, principally analgesia. The opiates include heroin (diamorphine) and morphine. In clinical practice opiates are predominantly used to manage pain, but they are also used as a cough suppressant and an antidiarrhoea agent. Opioids are synthetic opiates manufactured for medical use and have similar effects to heroin.

Opiates and the law

Heroin and other opiates are class A drugs under the Misuse of Drugs Act 1971. The maximum penalty for illegal possession of a class A drug is seven years’ imprisonment and/or a fine. The maximum penalty for supplying a class A drug is life imprisonment and/or a fine (NTA, 2004). Codeine and dihydrocodeine are class B drugs.

In 2002, according to the regional drug misuse database (Department of Health/National Treatment Agency for Substance Misuse, 2002), heroin was the most frequently used class A drug in England and Wales (67 per cent of users) among 16-59 year olds.

Opiates are used for medical and illicit purposes. In the UK methadone is now more readily available on prescription and illicitly. The cost of heroin has decreased and a gramme is now estimated to cost between £50 and £80, depending upon location, availability, supply and demand. The main sources of illegal opiates are Afghanistan, Pakistan and Iran.

Opiates can be smoked (known as chasing the dragon), snorted, injected or, more rarely, swallowed. Intravenous injection maximises the effects of opiates and is also the most dangerous route of administration.

Aetiology and risk factors

Opiate use is linked to socioeconomic deprivation, poor living conditions, inadequate nutrition, difficult relationships and crime (NAC/DoH, 2003). The most acute risk associated with opiate use is the potential for overdose, from both prescribed and illicit drugs. Groups most at risk, due to a decrease in tolerance, include drug users leaving institutions such as prison, or those who have been on detoxification programmes.

Opiates depress breathing rate and blood pressure, resulting in respiratory arrest. This effect is exacerbated if they are consumed in addition to other central nervous system depressants, for example benzodiazepines or alcohol.

It is estimated that 25 per cent of drug users may also have an alcohol problem (Prime Minister’s Strategy Unit, 2004). This makes opiates the illicit drug group associated with the most deaths in the UK, primarily as a result of overdose (NAC/DOH, 2003).

Non-injected opiates carry very little risk of chronic adverse health effects. Nevertheless, they can result in modest suppression of the immune system and hormone levels, constipation, respiratory complaints, menstrual irregularity, malnutrition, tooth decay, and decreased sexual desire and performance. Opiates may also cause complications in pregnancy, such as an increased risk of miscarriage, foetal death, low birthweight, withdrawal symptoms in newborns, and subsequent developmental consequences.

Mild to moderate mental health problems may accompany opiate use, such as depressive disorder, anorexia and lethargy. But opiates are not linked with chronic psychiatric disorders.

However, injecting opiates poses additional hazards. The sharing of needles, syringes and other injecting equipment increases the risk of contracting a bloodborne virus such as HIV, hepatitis B or hepatitis C. Skin abscesses, gangrene and lymphoedema are also associated with injecting drugs. Opiates may be adulterated and this, combined with a poor injecting technique, can result in deep vein thrombosis.

Chronic injecting may cause vein loss, which in turn can lead to the use of dangerous injecting sites such as the groin or neck. The role of needle exchanges is one of the most significant factors in reducing the incidence of HIV, hepatitis B and C among drug users (DoH, 2003).

While injecting is the most dangerous route of administration, smoking heroin may exacerbate respiratory conditions such as asthma. Intranasal use (snorting) is associated with impaired breathing, nose bleeds and the ulceration or inflammation of nasal mucosa. Swallowing tablets may result in long-term liver damage (NAC/DOH, 2003).

It is estimated that there are between 250,000 and 350,000 children of problem drug users in the UK. Parental drug use is known to cause serious harm to children and therefore effective treatment of the parent can have major benefits for the child (Advisory Council on the Misuse of Drugs, 2003).

Dependence

The International Classification of Diseases (ICD-10) (World Health Organization, 1992) defines drug dependence as:

- Subjective compulsion (craving);

- Withdrawal symptoms;

- Loss of control;

- Tolerance;

- Progressive neglect of alternative pleasures or interests;

- Persistent use despite evidence of harm;

- Narrowing of personal repertoire (taking the substance is more important than anything else);

- Rapid reinstatement after abstinence.

Jaffe (1985) argues that, while certain risks may be limited to more intensive use patterns, harm may also occur as a result of experimental or recreational use.

Opiates have a very high dependence potential (NAC/DOH, 2003). However, dependence is not an inevitable consequence of opiate use and the rate at which individuals become dependent varies. Tolerance develops and is characterised by the shortened duration and decreased intensity of central nervous system depressant effects and marked elevation in average lethal dose (NAC/DOH, 2003).

Physical dependence upon opiates results in withdrawal symptoms if they are abruptly stopped or significantly reduced.

Opiate withdrawal

Treatment of opiate withdrawal includes support and a carefully titrated medication regime, the most critical period being the first two weeks.

Over the past decade, responsible substitute prescribing has been emphasised to prevent prescribed substitutes finding their way into the illicit market and to reduce the incidence of overdose.

Withdrawal is not life-threatening, but it can be an uncomfortable and painful experience. Opiate withdrawal may occur without the individual even being aware of dependence, for example following treatment with opiates, such as during and after hospitalisation.

Withdrawal from heroin typically reaches its peak 36-72 hours after the last dose, and symptoms normally subside after five days. Withdrawal from methadone usually reaches its peak between four and six days after the last dose, and symptoms do not subside for 10 to 12 days.

Opiate withdrawal programmes may vary from a few weeks to a few months until detoxification is achieved. Non-opiate treatments such as lofexidine and buprenorphine are available to treat opiate withdrawal. The advantages are that they are less likely to be diverted into the illicit market or misused by the patient. Withdrawal can induce a variety of symptoms (Table 1, p31).

Diagnosis

A physical examination and a clinical history are necessary to diagnose opiate dependence and withdrawal. Typically, the examination involves looking for signs of drug misuse, such as needle track marks, skin abscesses and signs of withdrawal or intoxication. Another aim is the detection of complications of drug misuse such as anaemia, constipation, poor nutrition and dental caries.

Haematological investigations can be undertaken to establish the health status of the drug user, specifically haemoglobin, liver function tests, hepatitis B and C, creatinine and HIV antibodies. The clinical history will include past drug use, injecting behaviour, past complications of drug use, bloodborne virus status (if known), last cervical smear and menstrual period in women, operations and any accidents or head injuries.

Opiate use is usually confirmed by urinalysis or oral fluid swab and, less commonly, hair analysis. The duration of detectability in urine is about seven to nine days for methadone and 48 hours for codeine, morphine and propoxyphene. Heroin is detected as the metabolite morphine.

Treatment

Many people manage to stop using opiates, but it can take years before the craving subsides.

Withdrawal from all classes of drug can be achieved with no prescribing intervention, and some users withdraw themselves from opiates without medical assistance (known as cold turkey).

Where treatment is given it is influenced by the needs of the user and by the resources available. This may be in the community or a hospital setting.

An alternative approach to this are abstinence-based programmes, such as Narcotics Anonymous, which tend to be more prescriptive and less client-centred. They do, however, serve the needs of those who perhaps require a less flexible regime.

A range of psychosocial interventions based on a comprehensive assessment of need is recommended, addressing physical and mental health and a range of social needs such as housing and employment status. Management of opiate dependence and withdrawal is complicated, as it is necessary to establish the nature and extent of the dependency and what the person wishes to do about it. The range of options include stabilisation from chaotic to controlled drug use, maintenance prescribing, and the gradual withdrawal or detoxification from opiates (DoH/NTA, 2002).

Symptomatic interventions may be a suitable strategy for some and there are medications that are prescribed for low-level opiate users experiencing low-threshold withdrawal symptoms.

Some clients may benefit from treatment in a rehabilitation unit. This requires the person to be motivated, committed to abstinence and prepared to live away from their usual place of residence for a period of time. Relapse prevention is a crucial aspect of drug treatment. It is widely acknowledged that withdrawal and detoxification regimes have a high failure rate unless they are linked to long-term rehabilitation (DoH, 1999).

Nursing implications

Better outcomes are evident in patients who receive treatment for opiate withdrawal in a drug dependency unit rather than in a mental health unit. But a patient with opiate dependency and mental health difficulties requires support from a mental health team (DoH, 2003).

Marsden et al (2000) raise the issue of consulting with service users to gauge their perceptions of the treatment received, as satisfaction with treatment and care is likely to promote concordance. To facilitate this, Marsden et al (2000) devised the treatment perceptions questionnaire.

Learning objectives

Each week, Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:

- Understand what kind of drugs opiates are;

- Be familiar with their use in the health care setting;

- Know the risks of opiate misuse;

- Understand the symptoms of opiate withdrawal;

- Be familiar with treatment options for people who have misused opiates.

Guided reflection

Use the following points to write a reflection for your PREP portfolio:

- List your place of work and the type of patients you care for;

- Identify the main points the article makes about opiate misuse;

- Detail a new piece of information you have learnt about opiate misuse;

- Reflect on how an understanding of opiate misuse could help you in your area;

- Explain how you intend to follow up what you have learnt.

- This article has been double-blind peer-reviewed. 

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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