Guidance

Part 4: supporting opioid detoxification

Published 21 July 2021

Applies to England

1. Opioid detoxification

Opioid detoxification is a clearly defined process (usually with an agreed duration) supporting service users to safely and effectively stop using opioids while minimising withdrawals. The process varies in duration from person to person, usually lasting up to 28 days as an inpatient or up to 12 weeks as an outpatient. Service users who are ready to come off maintenance OST can choose to undergo opioid detoxification, but some service users may choose it when they first turn up for treatment.

It is best for service users to stay on a stable maintenance dose that works for them and then, if and when they’re ready, have a clearly defined detoxification. Sometimes the service user and a prescriber agree to reduce the dose slowly, but there is limited evidence that this is effective, and it does not constitute a detoxification.

1.1 Opioid withdrawal syndrome

Regularly using opioids builds up a person’s tolerance to the drug’s effects, meaning they will experience opioid withdrawal syndrome if they cut down or stop using opioids.

Noradrenaline is a brain chemical that increases the heart rate and speeds up breathing. When someone has regularly used opioid drugs, their brain has to work harder to release the right amount of noradrenaline. When they cut down or stop opioids, the brain is still working so hard to make noradrenaline that too much gets released. This excess noradrenaline is one of the causes of withdrawal symptoms.

You can read more about the signs of opioid withdrawal in part 1 of this guide.

You can also find more information about opioid withdrawal syndrome in PHE’s Routes to recovery from substance addiction manual. Page 74 covers how the brain reacts when cutting down or stopping opioids.

1.2 When and how to talk about opioid detoxification

Detoxification is an option for anyone newly seeking treatment and should always be considered and discussed with them. The focus of this chapter, though, is on detoxification for someone who has been stabilised on OST.

You can best support service users in maintenance treatment by regularly reviewing their care with them and by discussing whether detoxification should be considered with your multi-disciplinary team (MDT).

You might consider detoxification as an option in the following scenarios:

1. If the time feels right for the service user, they may simply request a detoxification or consider it as an option in the future. This could be because they feel ready or a significant life change could mean they want to make a change in their treatment as well.
2. If the treatment and recovery care plan review shows that a service user is benefiting from OST, they might be stable enough to start detoxification.
3. You, the service user, the prescriber or other involved professionals such as their GP might consider detoxification because of new or worsening physical and mental health conditions. You might for example consider opioid detoxification instead of maintenance for an older service user with a co-occurring respiratory condition. This is because the OST medication may exacerbate their respiratory condition and increase their risk of overdose.
4. You might consider detoxification if a service user starts a medication that has interactions with OST medication or has ongoing OST side effects.

Information and advice

When detoxification is being considered, you should first ask the service user what they know about detoxification, establish gaps in their knowledge or any misinformation and then give appropriate information and advice. You should do this with the prescriber and include the following as appropriate:

1. Explain the physical and psychological aspects of unmanaged or too-rapid opioid withdrawal, including the duration and intensity of symptoms, and how these may be managed. These symptoms are less likely with a slow, carefully managed detoxification.
2. Describe the pharmacological and non-pharmacological approaches to manage or cope with any opioid withdrawal symptoms that do occur. Non-pharmacological approaches include using distraction techniques for withdrawals and cravings, avoiding triggers and changing lifestyle factors that need particular attention during opioid detoxification. These include a balanced diet, adequate hydration, sleep hygiene and regular physical exercise.
3. Emphasise how important it is to continue to access support, as well as psychosocial and appropriate pharmacological interventions. This is to maintain abstinence, treat co-occurring mental health conditions and reduce the risk of adverse outcomes (including death).
4. Explain that opioid tolerance will be low after detoxification, so there is increased risk of overdose and death from using illicit opioids. This is further increased if also using other central nervous system depressants such as alcohol, benzodiazepines or gabapentinoids including gabapentin and pregabalin. Any combination of these types of drugs increases the risk of overdose and death, but particularly in people who have a low opioid tolerance.
5. People who are opioid dependent appear to be increasingly using illicit benzodiazepines. You should explain to service users that illicit benzodiazepines are commonly sold as alprazolam (often referred to as ‘Xanax’), diazepam (often referred to as ‘Valium’) and temazepam, but typically do not actually contain these drugs. They usually contain other dangerously potent benzodiazepines or their analogues such as flubromazolam, flualprazolam and etizolam.
6. Explain the high risk of relapse and how important it is to rapidly return to treatment or seek professional or peer support if this happens.

You, the service user and your MDT will need to consider the setting for the detoxification. Most service users will be detoxed in the community, but an inpatient detoxification might be appropriate if a service user:

• experienced adverse events during previous community-based detoxifications (including physical complications)
• needs medical or nursing care for significant co-occurring physical or mental health conditions
• requires detoxification from multiple drugs or alcohol
• will not easily be able to travel to and from the service on a daily basis during detoxification (this can be a factor in rural areas)
• has minimal support from family and friends and you cannot arrange peer support

1.3 Assessing if someone is suitable for detoxification

Before changing someone’s treatment from maintenance OST to detoxification, or starting a new service user on detoxification, it’s important to establish whether they are suitable for it.

You might decide that a service user is suitable for detoxification if:

• they are committed to and informed about the process (and understand that levels of motivation will vary throughout treatment)
• they are aware of the high risk of relapse and associated risk of overdose due to reduced opioid tolerance
• they have identified social support for change and planned how and when to make use of it
• plans for continuing support and treatment are in place

Initially, you should assess whether the service user is suitable for opioid detoxification, then the prescriber should do a more detailed assessment. Both assessments should:

• review current and previous physical and mental health problems, and any treatment for these
• consider the risks of reduced opioid tolerance and using drugs or alcohol as a response to opioid withdrawal symptoms or cravings
• consider the service user’s current social and personal circumstances, including social and peer support
• consider the potential impact of starting to use drugs again, including involving (with consent) family members and any dependants as appropriate (this includes assessing or reassessing potential safeguarding issues)

1.4 Pre- and post-detoxification treatment and recovery care planning

Where you are working with a service user on pre- and post-detoxification planning, you should:

• develop and agree an updated treatment and recovery care plan with the service user
• continue to focus on your therapeutic relationship with the service user through and beyond detoxification
• help the service user to identify situations or states when he or she is vulnerable to drug use (high-risk situations) and to explore alternative coping strategies
• recognise and harness service user strengths to build their confidence in achieving their goals
• ensure that they continue to have access to other local services, groups or communities that can provide support
• ensure that maintaining the service user’s engagement and rapid re-engagement with services remains a major focus of the treatment and recovery care plan including a plan for managing a lapse or relapse to using
• continue to work together with other care providers
• consider how to involve and support families and significant others or peers in the support plan

Your MDT can bring useful perspectives and ideas to pre- and post-detoxification treatment and recovery care planning.

Detoxification without carefully planned post-detoxification care is rarely successful. There is a high risk of relapse after detoxification. You should work with the service user before detoxification on strategies for getting them rapidly back in for reassessment, support and perhaps return to OST if they relapse. You should provide overdose information, as well as advice and training on naloxone, which are vital in case of relapse.

Keywork, psychosocial interventions and recovery support

Ongoing monitoring and support for behaviour change through keywork, psychosocial interventions and recovery support need to be in place during detoxification. This should include helping service users engage with aftercare services.

Access to recovery support provided by services and peers, including mutual aid, is vital after detoxification. This support can be a mixture of face-to-face, phone and digital contact, to regularly check-in with service users post-detoxification. It’s important to work with the service user to identify recovery and wellbeing, as well as employment, training and education opportunities, particularly for post-detoxification treatment and recovery care planning.

Relapse prevention including medication

Relapse prevention through keywork, groups and supported by medication (if needed) is vital during and beyond detoxification.

Naltrexone is a medicine that can be used as part of a relapse prevention programme built around psychosocial support. It is an opioid antagonist which, when taken regularly, blocks the brain’s opioid receptors. This means that if any opioids (such as heroin) are taken, they will not be able to trigger the opioid receptors and so will not cause any effect. When used after opioid detoxification, naltrexone is an effective treatment for opioid-dependent people who are highly motivated to stay abstinent. It should only be taken under adequate supervision by someone fully informed of the potential adverse effects of treatment (including the risk of overdose from any attempts to overcome the ‘blockade effect’ by taking large amounts of opioids).

Before someone starts naltrexone treatment, the prescriber will check:

• that the service user is opioid-free to avoid severe and prolonged withdrawal symptoms which may prompt illicit opioid use and increase overdose risk
• the service user’s liver function for any signs of liver disease, as this might mean they are unsuitable for this treatment, need their dose adjusted or need to be monitored

If a service user has been using opioids before they take naltrexone, they might experience severe and prolonged withdrawal symptoms. So, naltrexone should only be used if a service user is definitely opioid free, verified with opioid-negative drug tests. If a test is positive for opioids, then no naltrexone should be given.

Due to the rare toxic effect of naltrexone on the liver in some service users, liver function tests should be conducted before and during naltrexone treatment to check for existing liver disease and monitor liver function.

You should review service users on naltrexone regularly to assess how effective the treatment is. If opioid misuse becomes apparent, you should consider stopping naltrexone treatment.

Additional support from a keyworker or group where service users can discuss issues related to staying abstinent and test out new skills and behaviours may enhance the impact of the medication. You can further improve the outcome of naltrexone treatment by ensuring consumption is supervised by a pharmacist, a family member or carer. This will ensure that it is being taken as prescribed.

It is good practice to give service users a card to show others that they are maintained on naltrexone, in case opioid pain relief is considered, for example after an accident.

1.5 Support during and following detoxification

The last stage of detoxification can be particularly difficult for service users. Many service users find the last few milligrams the trickiest to reduce and still report feeling withdrawal symptoms. Service users may feel attached to their OST medication and fear the unknown of what life will be like without it. We asked a service user to tell us how that last stage feels.

I recall how difficult I found it when I had reached the last dose of my medication and was required to come off completely. At that time, I was already fearful of what was about to come which means I was aware I would soon have to manage without any illicit or prescribed drugs.

In my first attempt, I tried to just come off the lowest dose (2 milligrams) but found this too difficult and painful. The advice from staff was very cloudy and unclear. They seemed to think that there would be no withdrawal symptoms at this stage and therefore I required little attention. I recall feeling extremely tired, demotivated and lethargic. I am really surprised that there are not more resources put into dealing with this stage which I feel is the hardest part of treatment.

Withdrawal symptoms reported at very low doses of OST should be treated seriously. They may or may not be the body’s response to this final stage of detoxification, but they are affecting how the service user feels and so might affect their chances of completing detoxification. You can assess withdrawals using a scale, such as the Clinical Opiate Withdrawal Scale (COWS) or the Subjective Opiate Withdrawal Scale (SOWS). Discuss the results with the service user and prescriber to decide what additional support they might need.

Providing support for someone in these difficult stages is critical. Support might include:

• pharmacological management of any returning withdrawal symptoms, being careful not to substitute one dependence with another (for example, short-term benzodiazepines for anxiety, or temporarily increasing the dose before slowly trying to reduce it again)
• continuing or strengthening the psychosocial support that has been in place during OST (for example, regular keywork sessions, groupwork, peer support and mutual aid and also considering things like more check-ins and more involvement with peers)
• stepping up recovery support, including help to find work, education or volunteering

You will have already discussed preparing for a change in the nature of their treatment. Although the process will have started much earlier in treatment, the focus of their treatment is going to shift further away from medications and even more to non-medical support.

If someone lapses or relapses, you should offer them rapid support and, if they want and need it, seamless access back into treatment, including maintenance prescribing. Service users should know that inpatient detoxification is also an option at any time they need it in the future if they become dependent again. Even if the positive changes made were short-lived, it is important that you affirm these changes and the resilience shown during a difficult process.