Medication assisted treatment for opioid dependence: Information for the public
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Symptoms are similar for all opioids, but are of varying severity and duration depending on opioid taken. For example, physical symptoms of heroin withdrawal commence six to 12 hours after last use and last for approximately five days. Symptoms are very unpleasant, but are rarely life-threatening (providing adequate hydration and electrolyte balance is maintained) and include:
Severity of signs and symptoms may be assessed using validated withdrawal scales such as the Clinical Opiate Withdrawal Scale (COWS) available in Appendix 2 of the National Guidelines for Medication-Assisted Treatment of Opioid Dependence.
Buprenorphine (Suboxone®) is routinely used for opioid withdrawal management. In the outpatient setting, an authority must be obtained from the Drugs of Dependence Unit prior to commencing Suboxone in the community.
Since 4 April 2011, any GP may obtain an authority to prescribe for up to five patients at a time. Inpatients in a public hospital can be prescribed buprenorphine for up to two weeks for opioid withdrawal without an authority.
Suboxone should not be started until there is clear evidence of objective withdrawal (pupil dilation and piloerection are good indicators) and a COWS score of 6 or more to avoid the risk of precipitated withdrawal (see Appendix 2 of the National Guidelines for Medication-Assisted Treatment of Opioid Dependence for information on COWS). Suboxone doses should be administered under the direct supervision of the pharmacist and not given as take home doses.
The GP can prescribe a fixed daily dose or a flexible dose range (with upper and lower limits on any particular day) and can provide instructions for the pharmacist or withdrawal worker regarding dose titration.
Day 1 — 4 mg at onset of withdrawal and additional 2 to 4 mg 4 to 6 hours later prn if severe withdrawal
Day 2 — 4mg mane, additional 2 to 4 evening dose prn
Day 3 — 4mg mane, additional 2mg evening dose prn
Day 4 — 2mg mane, additional 2mg evening dose prn
Day 5 — 2mg mane then cease
It is recommended that buprenorphine is not continued beyond this - please phone the Alcohol and Drug Information Service (ADIS) and ask to speak to the duty doctor for further advice.
Symptomatic medications that may be helpful include:
Inpatient withdrawal is recommended if poly-drug withdrawal is anticipated, the person has social circumstances likely to make cessation of drug use difficult, or has significant physical or psychological co-morbidities (see the information about withdrawal settings on the page called Substance withdrawal management).
Suboxone remains the treatment of choice for opioid withdrawal uncomplicated by the need for acute analgesia, etc.
It is recommended that buprenorphine is not continued beyond this - please phone the Drug and Alcohol Clinical Advisory Service on 7087 1742 for further advice.
See SA Health Guideline for the medical management of people at risk of opioid withdrawal for detailed advice.
Alcohol and Drug Information Service (ADIS) 1300 13 1340
ADIS is a telephone information, counselling, and referral service.
Drug and Alcohol Clinical Advisory Service (DACAS)
DACAS provides a telephone and email service for South Australian health professionals seeking clinical information and clarification around clinical procedures, guidelines and evidence-based practice.
Telephone: (08) 7087 1742 from 8.30 am to 10.00 pm 7 days/week including public holidays or e-mail your enquiry to: HealthDACASEnquiries@sa.gov.au.
DACAS is available 24/7 for urgent overnight matters to hospital consultants, registrars and general practitioners covering emergency departments in rural/remote settings.
This service does not provide proxy medical cover and cannot assume responsibility for direct patient care.