Helping Drug Users; Without
Getting Struck Off
Dr Richard Watson
Glasgow Southern Medical Society

Bob Dylan

OPIUM POPPIES

PROBLEMS WITH
METHADONE
• Maintains dependence, though perhaps not
addiction.
• Few patients leave treatment.
• Diversion of methadone.
• Expense.
• Patient choice - some do not want it.

RAPID OPIATE
DETOXIFICATION
RAPID ANTAGONIST
INDUCTION
ROD/RAI
The Asturian Technique

NALTREXONE
• Blocks opiate receptors.
• Can be given three times a week.
• Give under supervision.
• 6 month relapse rate 40% vs 80% without
it.
• ? implant

Effective Interventions Unit /
GGHB
• Systematic review recommends increased
use of naltrexone.
• Methadone Review encourages “moving
patients on” from MMT.

DETOXIFICATION
• Residential programme very expensive.
• Community based programmes have a low
success rate.
• Rapid detox using naltrexone plus or minus
anaesthesia been practised for many years
on in-patients.

THE ASTURIAN METHOD
• At home - need a responsible carer.
• Exclude patients dependent on alcohol or
benzodiazepines.
• Other exclusions - pregnancy, significant
other disease.

FIRST DOSE
• S/c octreotide 200mcg
• clonidine 450mcg
• famotidine 40mg
• midazolam 22.5mg
• ondansetron 12mg
• clorazepate 50mg

45 MINUTES LATER
• Asleep, but shaken awake.
• Metoclopramide 10mg.
• Naltrexone 50mg

1 hour 45 minutes
• Again shaken awake.
• hyoscine 20mg
• clonidine 300mcg
• metoclopramide 10mg
• 30-60 minutes later withdrawals begin.

ATTEND THE NEXT DAY
• Continue naltrexone, orally or with implant.
• Some may stop naltrexone and not relapse.
• None of my patients able to attend the
following day.

ROD/RAI
• 3000 in Asturias, 99.8% attended the
following day.
• Four in Cambuslang. All stopped
naltrexone soon.
• Two seem free of opiates several years
later.

Reference
• Carreno JE, Bobes J, Brewer C, Alvarez,
CE, San Narciso GI, Bascaran MT, and
Sanchez del Rio J. 24- hour opiate
detoxification and naltrexone induction at
home - the “Asturian method”: a report on
1368 procedures. Addiction Biology (2002)
7, 243-250.

FINAL VERSION Drug misuse
Opioid detoxification
National Clinical Practice Guideline Number 52

Legal Drugs
• Tobacco
• Alcohol

ALCOHOL
“An Inn has one entrance and three exits:
to hospital, to asylum and to prison.”
(Croatian proverb)

Alcohol-related mortality

www.sign.ac.uk;

How Long Is Long Enough?
• Addiction is a chronic disease and not a
voluntary disorder (9)
• “180 Day Psychosocially Enhanced
Detoxification” no good.(10)
• Death Rates go up on discharge from
MMT (7,11)

References
• 1 Barnett P. G. “The cost-effectiveness of methadone maintenance as a health
care intervention.” Addiction. 1999, 94(4), 479-488.
• 2 Hulse G.K. et al “the quantification of mortality resulting from the regular use
of illicit opiates.” Addiction. 1999, 94(2), 221-229.
• 3 Donoghhoe M. C. Opioid overdose. Trends, risk factors and priorities for
action. WHO, 1998.
• 4 Best D. et al. Overdosing on Opiates. Drug and Alcohol Findings. 2000. 4, 4-
20.
• 5 Mattick R. “Are detoxification programmes effective?” Lancet. 1996, 347, 97-
100.
• 6 Desmond D.P. et al. Deaths among heroin users in and out methadone
maintenance. In: Effective Medical Treatment of Heroin Addiction. National
Institute of Health (NIH) Consensus Conference, November 17-19,1997,
Bethesda Md. Available at: http://odp.od.nih.gov
/consensus/cons/108/108_abstract.pdf:73-78

References
7 Gronbladh L. et al. Mortality in Heroin Addiction: Impact of Methadone
Treatment. Acta Psychiatrica Scandanavica. 1990. 82(3), 223-227.
8 Caplehorn J.R.M. et al. Retention in methadone maintenance and addicts risk of
fatal heroin overdose. Addiction. 1994. 89, 203-207.
9 McLellan et al. Drug Dependence, a Chronic Medical Illness: Implications for
Treatment, Insurance, and Outcome Evaluation. Journal of the American
Medical Association 2000. 284, 1689-1695.
10 Sees K, et al. Methadone maintenance versus 180-Day Psychosocially Enriched
Detoxification: A Randomised Controlled Trial. JAMA: March 2000: 283
(10)
• Magura S & Rosenblum A. Leaving Methadone Treatment: Lessons Learned,
Lessons Forgotten, Lessons Ignored. Mount Sinai Journal of Medicine: Jan
2001. 68 62-74

References
• 12 Hutchison SJ et al. One year follow up of opiate injectors
treated with oral methadone in a GP-centred programme.
Addiction. 2000. 95 (7) 1055-1068
• 13 Ward, Mattick and Hall. Methadone Maintenance
Treatment and Opioid Replacement Therapies. 1998.
Harwood Academic Publishers