For diagnosing withdrawal, the eyes have it

Recognizing and treating opioid dependence inside the hospital, and beyond.

A patient at your hospital claims she's going through heroin withdrawal and wants treatment. How do you know if she's telling the truth?

Check out her pupils, said Jeffrey H. Samet, FACP, chief of general internal medicine at Boston Medical Center and Boston University School of Medicine, at an Internal Medicine 2010 session on illicit drugs that focused mainly on opioid abuse.

Dr Samet You cant expect to cure the dependence during the hospital stay Photo by Kevin Berne
Dr. Samet: “You can't expect to cure the dependence during the hospital stay.” Photo by Kevin Berne.

“Dilated pupils can't be easily faked,” Dr. Samet said, while other symptoms of withdrawal can be seen in the hospital for a host of reasons. These include nausea, restlessness, a heart rate above 100 beats/min, abdominal cramps, sweating, runny nose and watery eyes.

When verified, withdrawal should be promptly treated. Not addressing it can prevent a physician from fully dealing with any other medical or surgical condition the patient has. In other words, this is not the time to make the patient go cold turkey.

“Withholding opioids will not cure the patient's addiction, and giving opioids won't worsen the addiction,” Dr. Samet said. “You can't expect to cure the dependence during this hospital stay.”

Methadone is the best treatment choice for opioid-addicted inpatients, he said. It's available in tablet, oral solution and parenteral forms; has an onset time of 30 to 60 minutes; and lasts about six hours for pain and 24 hours in preventing withdrawal.

Start with a 20-mg dose (“People don't stop breathing with this amount,” Dr. Samet said) and reassess every two to three hours, giving an additional 5 to 10 mg until withdrawal signs abate.

“Again, rely on the pupils to gauge withdrawal,” Dr. Samet said.

Be sure not to exceed 40 mg of methadone in 24 hours, and monitor the patient for central nervous system and respiratory depression. On the following day, give the patient the same total dose you gave in the previous 24 hours.

“Remember, the goal is to alleviate acute withdrawal; the patient will continue to crave heroin,” Dr. Samet said.

If the patient's drug test is positive for opiates on the second day of hospitalization, it is not the result of the methadone, he added. As a synthetic opioid, methadone won't show up. The results probably can be explained by residual heroin from before the patient's admission; any morphine the patient was given after admission; illicit opioid use during hospitalization (for example, if the patient left the floor to use); or even ingestion of a poppyseed bagel.

Beyond discharge

When it's time to discharge the patient, refer him or her for long-term substance abuse treatment, either through a treatment center or primary care doctor, Dr. Samet said. Agonist treatment, with either methadone or buprenorphine, is the best option. The two treatments work equally well, he said.

“To simply go out and stop using doesn't work that well. We wish it did, but there is a low rate of retention in treatment, and achievement of abstinence, for people who just try to detox and stop,” Dr. Samet said.

Indeed, fewer than half of those who try to quit opioids cold turkey stay abstinent at six months, and fewer than 20% are abstinent at 12 months, he said.

The goal of maintenance agonist treatment is to create a sort of “narcotic blockade” that alleviates cravings for the drug. “You begin to normalize the deranged brain changes and deranged physiology” from addiction, Dr. Samet said.

Patients need to be aware, however, that they may experience a state of chronic opioid withdrawal, even if they are taking agonists, that can last months or years. Symptoms include malaise, fatigue, poor tolerance to stress and pain, restlessness, cravings and insomnia.

“This can be a real problem for which you can tell your patient that, over time—months or years sometimes—these symptoms do tend to get better,” Dr. Samet said.

Methadone maintenance

Methadone maintenance therapy has many years of proven efficacy, Dr. Samet said.

“There's lots of data out there showing methadone increases overall survival, treatment retention, and employment. It decreases illicit opioid use, criminal activity and hepatitis/HIV seroconversion, and it improves birth outcomes,” he said. “So it's not perfect, but it is very helpful in terms of outcomes.”

Maintenance treatment is highly structured, and typically operates outside the standard medical world, through separate clinics. It involves daily dosing, daily nursing assessments, weekly individual and/or group counseling, random supervised urine screens, psychiatric services, and sometimes medical services.

“Individuals can eventually earn ‘take-home’ doses, if they have met the goals of the program long enough, so they don't have to come in every day,” Dr. Samet said. “It can be fun to ask patients whether they are getting take-homes, because it shows them you know something about opioid treatment.”

Access to methadone treatment can be limited, however, depending on where patients live. Five states have no methadone clinics at all, while four states have fewer than three, Dr. Samet said. Patients who do have access often view the treatment as inconvenient and highly punitive, because they must go in every day to get medicine, he added.

Other problems are the clinics' mix of stable and unstable patients, which can trigger relapses; lack of privacy; and the stigma against methadone use among physicians, peers and family, Dr. Samet noted.

“Also, to a certain extent, there is little ability to ‘graduate’ the program,” he said. “You are in the program for long periods of time.”

Buprenorphine plus naloxone

Buprenorphine has been shown in randomized controlled trials to be just as effective as moderate doses (80 mg) of methadone in terms of abstinence, treatment retention and decreased cravings, Dr. Samet said.

“If you ask me which is better [buprenorphine or methadone], I'd say they are both very useful,” Dr. Samet said. “I like them both, they both help, and it depends on the situation the patient is in. If the patient needs structure, methadone might be a good choice. But clearly, buprenorphine is easier, from a patient's perspective.”

A schedule III drug in the form of sublingual tablets, buprenorphine is typically taken with naloxone (combination trade name: Suboxone, Reckitt Benckiser Pharmaceuticals). When taken sublingually, naloxone isn't absorbed.

“So why is it there? Well, if you've been in the business of pain medication addiction, you know that everything that is given orally gets abused by some other route. So if you try to take Suboxone intravenously, you won't be happy … it will put you into acute withdrawal, because the naloxone is absorbed if given intravenously,” Dr. Samet said.

Suboxone, for which the typical maximum dose is 16 mg per day, also has high receptor affinity, slow dissociation and a ceiling effect for respiratory depression but not analgesia, he said. It should be given to patients while they are withdrawing.

“Otherwise, since it's a partial agonist and not a full agonist like methadone, and since it has strong receptor affinity, it will bump off full agonists from the receptor and put the person into withdrawal. So if they come [to the hospital] when withdrawing, [Suboxone] helps them stop withdrawing, and it's a fairly smooth transition,” he said.

Whether patients are taking Suboxone or methadone, Narcotics Anonymous can be a useful adjunct, as can outpatient counseling, Dr. Samet added.