6.8.1 PATIenTS WITH HIV/AIDS, HePATITIS AnD TB As described in section 5.6.8, opioid agonist treatment enhances adherence to treatment with anti-infective agents in patients with opioid dependence (see section 5.6.8 for a more detailed discussion).
When presented with an active drug user with TB and opioid dependence, the first priority of the treatment service should be to treat the active TB without spreading it further. If opioid dependence treatment can be commenced in a way that does not put other patients at risk, then this is ideal. Otherwise, it may be better to delay treatment until the patient is no longer infectious.
When presented with an active drug user with HIV and opioid dependence, it is simpler to delay antiretroviral treatment until the patient is stabilized on opioid substitution treatment than to attempt to start antiretroviral drugs before opioid substitution treatment.
There is no need to delay antibiotic treatments such as co-trimoxazole or isoniazid, if it is indicated.
6.8.2 ADOleSCenTS
Adolescents 12–18 years old present to treatment services with the full range of opioid-dependence severity. Some adolescents may be brought to the clinic by their families, who are concerned about recent drug
use that may not have reached the level of dependent use. On the other hand, many adolescents presenting to treatment services come from socially disadvantaged backgrounds, are living on the street and may have more severe dependence than many adult patients. In between these two groups is a third with dysfunctional families. Studies suggest that the earlier that substance use commences, the higher the risk of dependence and adverse health consequences[179].
Working with adolescents requires a sensitivity to the issues pertinent to adolescent health in general, because drug use is often a result of events occurring elsewhere in an adolescent’s life. Assessment should be broad and should include medical, psychological, education, family and other aspects of the adolescent’s life. Treatment should cover as many aspects of the adolescent’s life as possible. Given their special treatment needs, adolescents with opioid dependence often benefit from special health services aimed directly at them.
Treatment approaches should accommodate adolescents, who often have higher levels of risk taking, novelty seeking and responses to peer pressure than older individuals (probably due to incomplete development of brain areas of inhibitory control). Thus, training in self-control, resilience and decision-making should be included in psychosocial interventions. To ensure that treatment is as effective as possible, the treatment programme needs to be individualised and comprehensive, and needs to take into consideration an adolescent’s strengths, psychosocial supports, education, legal and medical status and history, and pattern of illicit drug use.
Recent research has provided important information about the clinical profile of opioid-dependent adolescents, and has underscored the high prevalence of comorbid psychiatric disorders among this population. Psychiatric disorders that often accompany opioid dependence include depression, post-traumatic stress disorder, conduct disorder and attention deficit hyperactivity disorder. Some of these disorders (e.g. depressive disorders) are more evident among opioid-dependent female adolescents than among their male counterparts.
It is unclear to what extent existing psychiatric disorders lead to “self-medication” with opioids and other drugs
among this adolescent population; however, addressing psychiatric comorbidity along with substance use is likely to lead to more effective, comprehensive care.
Adolescents may live with one or more parents, and are likely to still be in the legal custody of one or more parents. Parents may play a central role in the lives of adolescents entering substance abuse treatment, in comparison to adults entering treatment. Adolescents may thus be in need of family counselling, to improve relationships with parents or to help parents learn how to be as supportive as possible of their adolescent while that person is in treatment for their substance use disorder. High levels of parental involvement and low levels of parental detachment protect against opioid use among adolescents.
Experimentation with substance use often starts in adolescence; thus, Addiction. or substance dependence, has frequently been referred to as a developmental disorder. Providing effective interventions early in an adolescent’s drug involvement is critical if this progression is to be altered. Early intervention is particularly important in light of emerging research, suggesting that adolescents may progress from substance use to dependence more rapidly than adults. Additionally, substance use among adolescents may interfere with cognitive, social and emotional development[15, 180].
Effective early intervention for opioid-dependent adolescents – combining pharmacotherapy and psychosocial treatment – can help to prevent adolescents from following a substance-using life trajectory, and from transitioning from intranasal or oral to injecting opioid use. Moreover, early psychosocial intervention with young people who have used heroin but who are not yet opioid dependent can help to prevent young people from becoming dependent on opioids.
Should pharmacological treatment for adolescents with opioid dependence differ from that for adults?
No systematic reviews addressing this question were found. Some clinical trials were found that supported the use of agonist pharmacotherapy, both for opioid withdrawal and maintenance. One RCT demonstrated that, compared to clonidine patches, 28-day reducing
51 Patient level guidelines – for clinicians
buprenorphine retained more people in treatment (72% versus 39%), and led to higher rates of induction to naltrexone (61% versus 5%)[181].
The use of agonist pharmacotherapy is still the recommended therapy for adolescent opioid dependence. However, adolescents with a short period of dependence and those living in families may respond to opioid withdrawal with or without naltrexone, and these would be reasonable alternatives. Opioid agonist pharmacotherapy in this population can also be started on an interim or trial basis, and short-term therapy may be all that is required if the response is positive.
A comprehensive treatment programme that addresses this entire clinical profile is more likely to produce better outcomes than a programme that focuses on one clinical problem in isolation.
6.8.3 WOMen
Women have been found to differ from men in their drug-use patterns, with women using less quantity but advancing more quickly to dependence, and using more prescription sedatives. Women who become opioid dependent are more likely to have less education, fewer financial resources and higher rates of sexual and physical abuse[183]. Often, the needs of women in substance dependence treatment settings are also different. They are more likely to have child-care responsibilities that may limit access to treatment, and they may be reluctant to participate in group psychosocial activities with men.
They also report significant rates of sexual harassment by male treatment staff[183].
Data are lacking on the relative efficacy of gender-specific services for women. To retain women, services may need to provide either individual or female-only group counselling, cater for people with small children (e.g. provide child-care facilities), and have measures to guard against sexual harassment of female patients by male staff.
6.8.4 PReGnAnCY AnD BReASTFeeDInG
For women who are pregnant or breastfeeding, opioid agonist maintenance with methadone is seen as the most appropriate treatment, taking into consideration
effects on the fetus, neonatal abstinence syndrome, and impacts on antenatal care and parenting of young children. Opioid-dependent women not in treatment should be encouraged to start opioid agonist maintenance treatment with methadone or buprenorphine. Pregnant women who are taking opioid agonist maintenance treatment should be encouraged not to cease it while they are pregnant. Although many women want to cease using opioids when they find out they are pregnant, opioid withdrawal is a high-risk option because a relapse to heroin use will affect the capacity to care for the child. In addition, severe opioid withdrawal symptoms may induce a spontaneous abortion in the first trimester of pregnancy, or premature labour in the third trimester. Relapse to heroin use during pregnancy can also result in poorer obstetric outcomes. Opioid agonist maintenance is thought to have minimal long-term developmental impacts on children when compared to the risk of maternal heroin use and resulting harms.
Methadone is preferred over buprenorphine because of the longer experience of the safety of methadone in pregnancy compared to buprenorphine, despite the fact that early research with buprenorphine suggests that its use may result in less neonatal abstinence syndrome than occurs with the use of methadone. If women are being successfully treated with buprenorphine, then the benefit of staying with a treatment that is working should also be taken into consideration.
In the second and third trimester, methadone doses may need to be increased, due to increased metabolism and circulating blood volume. Splitting the dose into two 12-hour doses may produce more adequate opioid replacement in this period. After birth, the dose of methadone may also need to be adjusted as some of these changes reverse.
Although methadone and buprenorphine are detectable in breast milk, the levels are low and are not thought to significantly affect the infant. Breastfeeding, on the other hand, has many benefits, including mother–infant bonding, nutrition and prevention of childhood illness.
Opioid-dependent mothers should be encouraged to breastfeed, with the possible exception of HIV-positive mothers or those using alcohol or cocaine and
amphetamine type drugs; in such cases, specific advice should be sought.
Untreated neonatal abstinence syndrome can cause considerable distress to infants and, in rare cases, can cause seizures. Cochrane Collaboration reviews indicate that opioids and barbiturates are more effective than placebo or benzodiazepines, with opioids probably more effective than barbiturates.
Recommendation
Opioid agonist maintenance treatment should be used for the treatment of opioid dependence in pregnancy.
Strength of recommendation – strong
•
Quality of evidence – very low
•
Recommendation
Methadone maintenance should be used in pregnancy in preference to buprenorphine maintenance for the treatment of opioid dependence; although there is less evidence about the safety of buprenorphine, it might also be offered.
Strength of recommendation – standard
•
Quality of evidence – very low
•
6.8.5 OPIUM USeRS
People dependent on opium who are suffering harm as a result can be treated with opioid agonist maintenance treatment, consistent with the approach for dependence on other opioids. Two trials have demonstrated the effectiveness of buprenorphine in this population[184, 185].
It is important to ensure that opium smokers meet criteria for opium dependence beyond simple tolerance and withdrawal. If unclear, it may be wise for opium smokers to attempt withdrawal first before commencing opioid agonist maintenance treatment.
6.8.6 DRIVInG AnD OPeRATInG MACHIneRY
Opioid intoxication can occur during induction onto methadone or buprenorphine. Patients should be advised not to drive while sedated. As patients will not know what effect their first few methadone and buprenorphine doses will have on them, they should be advised not to plan to drive at this time.
6.8.7 PSYCHIATRIC COMORBIDITY WITH OPIOID DePenDenCe
Psychiatric comorbidity with opioid dependence is common; in particular, depression, anxiety, personality and post-traumatic stress disorders should be specifically looked for early in treatment and on a regular basis thereafter. As with medical comorbidity, there is likely to be a greater uptake of treatment if the treatment can be provided by the same medical practitioner or at the same facility in an integrated service. Failing that, strong links with other services should be established to facilitate referral and to establish the framework for joint involvement; such a framework should include clarification about prescribing of psychoactive medication and about giving the patient a consistent therapeutic message.
6.8.8 POlYSUBSTAnCe DePenDenCe
Annex 12 lists the acute and chronic interactions of opioids, alcohol, benzodiazepines, stimulants and cannabis.
In the treatment of polysubstance dependence, opioid agonist maintenance treatment can be started for the opioid dependence component, in an inpatient facility if necessary, while the person is simultaneously withdrawn from alcohol, benzodiazepines and stimulants.
For withdrawal from high doses of benzodiazepines, gradual withdrawal may be necessary. If benzodiazepines are to be given to outpatients on opioid agonist maintenance treatment, this should be done carefully, because there is little evidence to support the long-term use of these drugs and they increase the risk of sedative overdose. If gradually reducing doses of benzodiazepines are prescribed to facilitate the safe withdrawal from benzodiazepines, the prescription should be from a single practitioner, and the dispensing should occur with administration of the dose of methadone, if possible. Patients should be discouraged from withdrawing from opioid agonist maintenance before ceasing benzodiazepines.
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