Treatment of heroin addiction

Treating heroin addiction is a lengthy and complex process that can take years and involves various professionals, not just healthcare workers, given the social implications of the disease. Pharmacologically, unlike with cocaine, there is a wide range of options available, the effectiveness of which has been tested in numerous studies in recent years. Some of these studies have demonstrated the effectiveness of administering unadulterated heroin of non-lethal purity under hygienic conditions.

Intoxication and withdrawal syndrome

Acute poisoning/overdose: The presence of the characteristic triad of symptoms definitively guides patient management. However, opioids such as tramadol can cause intoxication with agitation, elevated blood pressure, elevated heart rate, and seizures. Given the depressant effect on respiration, the first step is to secure the airway; therefore, an oxygen mask should be applied. Intubation is reserved only for cases where there is suspected aspiration of gastric contents into the lungs (bronchoaspiration) or lack of response to the antidote. A peripheral intravenous line should be inserted to adequately hydrate the patient with normal saline. In cases of tablet ingestion (fentanyl, tramadol, etc.), gastric lavage combined with activated charcoal and substances that accelerate defecation is recommended.

Unlike cocaine, heroin, and opioids, they do have an antidote. naloxone It is a substance that acts as an antagonist of heroin/opioid receptors; that is, it binds to these receptors, blocks them, and prevents the effects resulting from their activation. It is administered intravenously. The dose is adjusted based on the patient's condition and the type of substance consumed (in the case of synthetic opioids, the dose must be higher). The greater the respiratory compromise, the higher the dose. The response to the antidote is usually sudden, and the patient typically awakens abruptly; if this does not occur, another cause of respiratory depression and decreased level of consciousness should be suspected. To assess for secondary organ damage, blood tests are necessary to rule out rhabdomyolysis and kidney damage, and a chest X-ray is needed to rule out acute pulmonary edema. These complications require medical management and treatment.

 

Unlike cocaine, heroin, and opioids, there are antidotes. Naloxone is a substance that acts as an antagonist of heroin/opioid receptors; that is, it binds to these receptors, blocks them, and prevents the effects resulting from their activation.

Abstinence syndrome: As previously explained, this is a distressing and alarming condition for the person experiencing it, but it is not life-threatening. The only consequence is that intense cravings can lead to further use, with all the implications that entails. Opioid Withdrawal Syndrome (OWS) can be treated with two pharmacological options: clonidine and lofexidine (not marketed in Spain). These drugs regulate the release of norepinephrine and therefore alleviate withdrawal symptoms. Their use is restricted to hospital settings because they can cause significant drops in blood pressure and heart rate. The other alternative involves full/partial opioid agonists such as methadone or bruprenorphine. These medications can improve OWS, but they are part of a maintenance treatment and will be explained in the next section. In summary, the first option is used for a short period, while the second can be prescribed for months or years.

Heroin addiction: The therapeutic approach to this addiction, like any other, is complex and requires a multidisciplinary team of professionals. Typically, the organic destabilization and withdrawal syndrome make it difficult to begin psychotherapy from the outset. How do we stabilize the patient? The first step is to understand the repercussions of heroin use—detecting HIV, hepatitis C/B, tuberculosis, and damage to various organs—and then to alleviate the withdrawal syndrome. What options exist?

A) Methadone

It is a synthetic opioid that acts as an agonist. It began to be used in the 60s but was synthesized by Nazi scientists at the end of World War II. It can be taken in liquid or tablet form. The liquid form is the most common at pharmacies.

Methadone treatment has been widely used and studied. Its high efficacy in treating heroin/opioid addiction and reducing its consequences in all areas has been proven. Methadone does not produce the euphoric and euphoric effects of heroin, but it does share some of the same side effects, such as constipation, decreased libido, and amenorrhea.

What is the most appropriate dose of methadone? Individual characteristics of the person must be taken into account (presence of diseases, other pharmacological treatments, adverse reactions, etc.) but, in general, clinical experience tells us that doses above 50 mg per day are associated with greater continuity in treatment and a lower percentage of relapses.

 

Methadone treatment has been widely used and studied. Its high efficacy in treating heroin/opioid addiction and reducing its consequences in all areas has been proven.

When a patient has been abstinent for a sufficient period of time (not only heroin but also other substances) and demonstrates psychological, social, familial, and occupational stability, the healthcare professionals treating them can consider a gradual and progressive reduction in the methadone dosage. This process must be taken very seriously, with frequent and regular monitoring, due to the risk of psychological destabilization and relapse.

B) Buprenorphine

Like methadone, it is a synthetic opioid, but it differs in its mechanism of action; that is, it acts as a partial agonist. This means that it binds to receptors with high affinity, but the activation of these receptors is much less than in the case of a pure agonist. Initially, it began to be used as an analgesic, but in 1995, France authorized its use as a maintenance treatment for addiction to heroin or other opioids. Therefore, there is less experience with it than with methadone.

It is usually administered in tablet form, which must be placed under the tongue to be absorbed, often in combination with naloxone. Why? When buprenorphine was initially prescribed alone, some patients crushed the tablets and administered them intravenously. Naloxone is not absorbed sublingually, but if administered intravenously, it can trigger a withdrawal syndrome.

In general, buprenorphine It has fewer side effects than methadone, and withdrawal is easier. The price is higher, and clinical experience is not as extensive, although many trials and studies have been conducted in the last 10 years.

 

In general, buprenorphine has fewer side effects than methadone, and withdrawal from it is easier.

Besides partial and full agonists for maintenance treatment, there is the option of using antagonists—substances that bind to receptors, block them, and prevent the effects resulting from their activation. As we saw earlier, the antidote (naloxone) for acute heroin intoxication/overdose is an antagonist. Naloxone is not used in maintenance treatment because its oral absorption is undesirable and its duration of action in the bloodstream is short.

The alternative is naltrexone. This is well absorbed orally and remains in the bloodstream for a long time; furthermore, its antagonistic potency is greater. How is it used? If the individual has recently used heroin/synthetic opioids, naltrexone displaces them from the receptors in the brain and triggers a withdrawal syndrome; therefore, it is not indicated for these situations but rather for those in which the person has been abstinent for a considerable time—there is no longer any heroin in their body—but is at risk of relapse. Because naltrexone is blocking the receptors, the beneficial aspects of drug use—euphoria, well-being, etc.—are not experienced. Therefore, the goal is that the individual, lacking positive reinforcement from drug use, loses interest in it and the associated behaviors.

Regarding the psychotherapeutic aspect of the treatment, we can say that cognitive behavioral therapy, in combination with opioid agonist treatment, has proven to be the one with the best response and outcome.