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Whether Or Not To Detox the Five Year Opiate Patient – Who, What, When, Where, Why, and How
There are many factors that influence the success of opiate detox in the five year user. Deciding candidacy for complete detox is, at present, less a process of checks and balances and more a process of trial and error. So, many physicians steer away from this risky process even if it is in the patient’s best interest. Many physicians sense these patients don’t want to risk feeling sick so why push them. As a result, the federal government has instituted initiatives to encourage physicians and patients to make an effort to reduce or eliminate opiates from their care (Fiellin & O’Connor, 2002). Contracts, reading aloud discharge instructions at each and every office visit that detail the current plan as well as access to medical care in case of depression or cravings, communication between physicians the patient has used, prescription data bank retrieval at every office visit, reliable drug screens, and complete physician availability are all encouraged to minimize risk of relapse (Farag, 2008).
In the five year opiate user that wants to come off, the age and maturity of the patient clearly drives goal oriented behavior and potentially influences success. In general, young opiate dependent users have greater difficulty coming off opiates altogether, but perhaps should receive more exhaustive attempts to possibly avoid years of unnecessamaary care and expense (Woody et al., 2008).
Type A personality patients have long been known to detox from opiates easier than Type Bs (Sees et al., 2000). Methadone literature exists confirming that strong willed five year users have greater success in coming off and staying off opiates when the proper care is instituted to assist them. Dual care from both a counselor and a doctor will not only identify problems but also accentuate the triggers of motivation that maximize drive (Butcher et al., 2010).
Hereditary disorders play an important role producing moderately poor prognosis subtypes due to an interconnected array of personality disorders, anxiety, and depression states (Kuncha, 2007). Chronic anxiety, often familial, drives up the need to self-medicate with opiates (Grant et al., 2004). The user, five year or otherwise, with genetic risk must be identified and should be tapered down cautiously only by a specialist with every adjunct available, pharmacologic and non-pharmacologic (Kendler et al., 2012). Even these physicians consider avoiding full detox if alternative treatment modalities have failed or produced more side effects than the single, detoxing agent, buprenorphine, now available to physicians specially licensed by the DEA with an X number (SAMHSA, 2005). As they are induced and detoxed, the patient discovers benefit from this medication for their anxiety. Standard anti-anxiety medications should then be employed in an effort to remove the patient from buprenorphine. If traditional anti-anxiety cocktails fail or are poorly tolerated, the patient may opt to stay on buprenorphine instead in an off-label setting. If their control is either so remarkable and or well tolerated in comparison to existing standard of care pharmacopeia, physician and patient may elect to maintain this life restoring stability by continuing the buprenorphine (AMA, 2012). The welfare of the patient is a physician’s number one concern.
Chronic depression states like major depressive disorders may also similarly benefit from the single drug, buprenorphine, over traditional failed cocktails of tricyclics, SSRIs, and SNRIs (Watkins et al., 2011). These patients are often suicidal when in poor control. They discover opiates in their first five years of depression so often present in their twenties (Lubman et al., 2009). They know personally the limits of psychotherapy and toxicities of antidepressant medications and electroconvulsive therapy. They have histories of rashes, hangovers, and various degrees of lethargy and malaise caused by traditional anti-depressant care which often drove them to opiates in the first place (Stein et al., 2004). Ongoing psychiatry consultation is strongly recommended in this setting, establishing ongoing lines of communication between the buprenorphine prescriber, psychiatrist, and patient as long as care is provided. These five year users should consider maintenance on buprenorphine in an off label setting until an anti-depressant regimen can be formulated to match the safety and success they find on it (Weiss et al., 2011).
Any personality disorder in general has a component of anxiety associated with it and thus puts this five year opiate user at greater risk for not succeeding in detoxing from opiates ever (Hasin et al., 2011). It is important to identify the degree of chronic anxiety and depression within the disorder because these affective components are what will make detox high risk and maintenance on a long acting opiate perhaps beneficial.
Whether or not there is much anxiety or depression though, dependent personality disorders in particular exist that produce an even greater difficulty in coming off opiates in and of themselves (Hasin et al., 2011). And their co-morbid dependencies like cigarettes, marijuana, and alcohol make these patients easy to identify (American Psychiatric Association, 2000). Dependent personality types unfortunately are particularly refractory to treatment despite their enthusiasm to come off prescribed drugs (Tsuang et al., 1998). The dependent personality patient, especially if they have a component of anxiety or depression to their disorder, should consider maintenance over detox (Kleber, 2008; Sees et al., 2000).
History or ongoing problems with the law increases the need for early detox (Chandler et al., 2009). Maintenance as the long term plan must be discouraged in all patients in which diversion is suspected. Detox must be stepped up the moment diversion becomes a concern (Fiellin & O’Connor, 2002). The goal should be to disable access to opiates from these people as soon as possible (Chandler et al., 2009).
So, in summary, who to detox in the five year opiate user group? Certainly any patient with any kind of criminal record regardless of risk should be detoxed with an urgency to remove access to opiates as soon as possible, including traditional and alternative opioids like buprenorphine. Who not to detox in this group: all with chronic pain that have failed conservative care that may be more harmful than buprenorphine; all chronic anxiety patients that have failed conservative care that may be more harmful that buprenorphine; every single major depression disorder patient that has failed conservative care that may be more harmful that buprenorphine; dependent personality disorders especially if a long history of other substances of abuse predates their five years of opiate use.
Buprenorphine must be considered for all opiate users who present for care, five year users and otherwise (SAMHSA, 2005). Because of the increased availability of buprenorphine and decreased cost, no patient interested in detox that is a novice to methadone should be induced on that dated long term opiate henceforth (SAMHSA, 2005). The licensed buprenorphine prescriber should stabilize the patient according to current guidelines with an immediate eye to finding the best dose of buprenorphine based on response, compliance with care, and tolerance in a process known as induction. Maintenance follows for at least three months. In that time, the patient should be better assessed for detox vs. ongoing maintenance.
Timing is everything when it comes to decisions involving opiate detox in the complicated patient seeking care. The five year opiate user who intends to come off opiates entirely should be detoxed as soon as possible to avoid hitting ten years of use (SAMHSA, 2005). If the five year opiate abuser is to be detoxed from opiates altogether, there should be no delay in starting at least trials of small tapers as soon as three months of maintenance ends. If risk is questionable or if the patient has greater concerns, a small weekly reduction in buprenorphine dose should be attempted to reassure them of the safety of the process ahead. If their enthusiasm for detox is maintained, the subsequent detox will fare better (Marsch et al., 2005). The small taper also provides the clinician a look into the accruing nature of this long acting opiate’s possible effects in them by carefully questioning the patient about responses felt two, three, and four days after the single taper. Signs of withdrawal that occur in a delayed fashion like this means that a tincture of time as well as adjunctive care may necessary before a similar taper would be tolerated with more permanence. Intolerance means that the taper will be better tolerated in a month (Woody et al., 2008). Intolerance a month later may or may not be sufficient to avoid the taper then even. But the patient is given hope in that trend is in their favor and adjunctive care be stepped up to improve chances of success in a subsequent month (SAMHSA, 2005).
Current and ongoing cravings present a special though massive problem in the detox resistant patient and need to be addressed at every visit if out-patient detox is to work (SAMHSA, 2005). If it hasn’t already occurred, a need to remain on opiates definitely begins some time after five years of use (O’Connor, 2010). Headaches or sleep disturbances uncharacteristic of short term withdrawal may start in these more impaired patients months after every attempt to complete tapering, often leading patients to work ups run by countless specialists. There is limited data on these particularly refractory opiate dependent patients who may need to eventually consider low dose maintenance (Hall et al., 2008).
The five year opiate dependent patient now has more of a realistic choice as to where to detox safely from all opiate use: home vs. in-patient. Another advantage of the newer, long half-life opiate, buprenorphine, is the ease of which it allows for safe stay-at-home detox (SAMHSA, 2005). It is now generally accepted that compliance and safety can be maintained as an out-patient easier on buprenorphine than with methadone (Mitka, 2003). Follow-up can be adjusted according to progress. But out-patient follow-up, as we learned with years of methadone prescribing, can also be stepped up through times of stress (O’Brien, 2008). And re-checks can increase for non-compliance like resistance to non-opioid medications, or the self-adjusting of prescribed opiates. The ever looming possibility that a physician may increase follow-up regardless of progress minimizes indiscretions (Rosenblum et al., 2003). Compliance with doctors orders, often regarded as suggestions in the out-patient setting, needs to be mandatory with these patients and can be assured by stepping up follow-up or rewarding the patient with less frequent re-checks as the case may be (Rosenblum et al., 2003).
Despite the advent of buprenorphine, many patients will not respond to out-patient care for opiate detoxification (Vastag, 2003). Occasionally necessitating 15-30 day in-patient stays, the opiate detox patient comes to value his out-patient status. A prime candidate for in-patient wellness social detox is in the poly substance abuser. Those patients tend to benefit from longer 30-90 days stays. Still highly regarded today, older studies document effectivity of 180 day courses for even the occasional alcohol only or opiates only “specialist” (Sees et al., 2000).
While stress management represents one of the most useful tools aiding the clinician in detoxing the five year opiate user, it also calls to mind one of the main reasons why physicians should strive to detox these grey zone patients in first place. Stressors, good or bad, will forever lead opiate dependent patiens to take more and more opiates if they have access to them, traditional or non-traditional (O’Connor, 2005). The patients cannot easily substitute ways of dealing with stress outside of making opiate adjustments to alleviate their malaise. Their mental intake assessments tend to reveal psychiatric histories that need not be genetic — abuse within the family unit, loss of a job, and like stressors must be identified thorough questioning before care begins. Methadone advocates induce the five year user onto methadone in an effort to corral the addict but with no hope of removing the methadone once it is on board. With buprenorphine, the stabilization of life is the same, but hope for possible full removal now becomes an option in less than half a year (SAMHSA, 2005).
If the decision to come off opiates altogether is made by the five year user that has no genetic history of psychiatric disorders and no chronic pain, the following tools will facilitate successful tapering. If tapering is going well without harnessing them, they may be used to force a more difficult taper down the line (SAMHSA, 2005). If a taper fails, the following can be revisited again and again, finessing or intensifying parameters of the clinical pearl. And if everything is optimized, and a taper still fails, then a tincture of time itself often produces a different brain with fewer opiate receptors in play to treat (Kuehn, 2005). Thus, realistic hope is always available for the detox patient and everything learned throughout the process can be interpreted as progress.
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