The Pharmaceutical Journal
Vol 279 No 7462 p91
28 July 2007

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Offer methadone or buprenorphine first line for opioid detoxification

Methadone or buprenorphine must be offered as first-line treatment for opioid detoxification, which should be an option for opioid-dependent drug misusers who want to quit, according to National Institute for Health and Clinical Excellence guidance on substance misuse.

In its latest set of advice, NICE has also recommended varenicline, within its licensed indications, for those who want to quit smoking. It should normally be prescribed only as part of a programme of behavioural support, NICE says.

The clinical guideline on opioid detoxification specifies that, when deciding between methadone and buprenorphine, health care professionals should take into account what maintenance treatment the patient is already receiving and if they have a preference for either drug.

It adds that lofexidine may be considered for people who have made an informed and clinically appropriate decision not to use methadone or buprenorphine or who have decided to detoxify over a short time. It may also be considered for those with mild or uncertain dependence. Clonidine and dihydrocodeine should not be used routinely, it adds.

The guideline states that the starting dose for detoxification will depend on the severity of dependence, the stability of the service user, the pharmacology of the drug and where detoxification takes place. Detoxification should normally last up to four weeks in an inpatient or residential setting and up to 12 weeks in the community.

A range of financial incentives, referred to as contingency management, should be considered, says NICE. Rewards, usually vouchers that can be exchanged for goods or services, will be dependent on presentation of drug-negative tests.

A separate clinical guideline on psychosocial interventions advises that drug misusers who have limited contact with misuse services, for example those attending needle and syringe exchange schemes, and who are concerned about misuse, should be offered two motivational sessions. These should last 10–45 minutes, explore the patient’s ambivalence about drug use and possible treatment and provide non-judgemental feedback.

Information should also be offered to these patients about reducing exposure to blood-borne viruses. Specifically, advice should be given on reducing sexual and injection risk behaviours and tests for blood-borne viruses should be offered.