Optimizing Chances for Successful Outpatient Opioid Detoxification

Summary and Comment |
January 13, 2017

Optimizing Chances for Successful Outpatient Opioid Detoxification

  1. Joel Yager, MD

One week of escalating oral naltrexone administration achieved better results than standard buprenorphine induction in transitioning patients to extended-release naltrexone injections.

  1. Joel Yager, MD

The contemporary epidemics of opioid abuse and overdose demand effective outpatient treatment options. Intramuscular extended-release (XR) naltrexone (an opiate antagonist) offers one option, but guidelines recommend 7 to 10 days of abstention from opiates beforehand to prevent precipitated withdrawal. This abstention period has proven problematic, and relapse rates have been high. These researchers compared the standard buprenorphine induction strategy before XR-naltrexone injection with a detoxification protocol assisted with oral naltrexone.

The 150 opiate-dependent adults were openly randomized in a 2:1 ratio to the protocols (mean age, 35; women, 14%; white, 64%); 37% primarily used prescription opioids (rather than heroin). Naltrexone-assisted induction consisted of a single buprenorphine dose followed by 7 days of escalating oral-naltrexone doses, along with clonidine and other medications. Buprenorphine assistance involved 7 days of decreasing buprenorphine doses, followed by a week-long delay before XR-naltrexone injection.

Rates of moderate-to-severe withdrawal symptoms were low for both groups, and adverse events were generally consistent with mild withdrawal. Successful transitions to initial injections were achieved by significantly more oral-naltrexone patients than buprenorphine patients — 56% vs. 33%. Overall, prescription-opiate users were almost four times more successful than heroin users in successfully transitioning to XR-naltrexone. Successful second XR injections 5 weeks later occurred in 50% of the oral-naltrexone vs. 27% of the buprenorphine-assisted groups. Ongoing abstinence in weeks 4 and 5 after successful transitions was similar (oral naltrexone, 81%; buprenorphine, 88%).

Comment

Oral naltrexone-assisted patients transitioned to XR-naltrexone on day 8 at significantly higher rates than did buprenorphine-assisted patients who transitioned on day 15, and the majority achieving transition returned for second injections. These findings represent higher transition and retention rates than those in many previous reports; however, better methods are still needed, especially for heroin users.

Editor Disclosures at Time of Publication

  • Disclosures for Joel Yager, MD at time of publication Editorial boards Bulletin of the Menninger Clinic; Eating Disorders Review (Editor-in-Chief Emeritus); International Journal of Eating Disorders; UpToDate; FOCUS: The Journal of Lifelong Learning in Psychiatry

Citation(s):

Reader Comments (2)

GVL MBBS Resident, Psychiatry, Bengaluru, India

Why is 2:1 protocol used?
There are few important things
1. Most are prescription drug users who donot have signifcant withdrawals
2. Week delay of the taking naltrexone might have contributed to some of the positive findings

USHASREE WARRIAR MBBS DMRT BCCPM Physician, Oncology, cochin cancer research center

ioral morphine/codiene/hyoscine butyl bromide use guidelines please

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