Heroin withdrawal in general practice



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DACAS FAXSHEET 1

HEROIN WITHDRAWAL IN GENERAL PRACTICE



Individuals using heroin regularly (e.g. daily) over an extended period of time are likely to experience withdrawal when ceasing or reducing their heroin use. Good planning can assist withdrawal from heroin and many people will benefit from assistance from their general practitioner.


  1. ASSESSMENT



History





  • Drug use: quantity (amount, cost, number of injections per day), frequency, duration, route of admin, when last used, features of dependence.

  • Use of other drugs, (e.g. benzodiazepines, alcohol, etc).

  • Withdrawal history; what has worked / not worked in the past.

  • Home environment and social supports.

  • Medical & Psychiatric history.

  • Pregnancy.

  • If concerned re drug seeking behaviour, check with Drugs & Poisons Unit (Monday to Friday 9-5 on 9412 7777)



Examination





  • Vital signs (BP, pulse, respiratory rate)

  • Evidence of intoxication (pinpoint pupils, sedation, slurred speech, lowered BP, slowed pulse) or withdrawal from heroin (see below) or other drug use

  • Evidence of complications of injecting drug use, including injection sites, liver, lymphadenopathy, cardiac, mental state.



Investigation





  • Urinary drug screen can be helpful in confirming the history.

  • Consider LFT’s, HIV, Hep B&C testing at some stage with appropriate pre & post test counselling (generally when withdrawal completed)




  1. PLANNING WITHDRAWAL

In most cases, heroin withdrawal can be safely completed in the patient’s home if there are sufficient supports, however there are some exceptions:


Contraindications





  • Unstable medical /psychiatric condition

  • Unclear history of drug use

Relative Contraindications


  • Pregnancy -consider referral for methadone maintenance. Withdrawal during pregnancy can lead to miscarriage or premature delivery.

  • Unsupportive home environment (e.g. other drug users in the home or no-one to safely supervise).

  • Polydrug dependence (in this case you may need to discuss with a specialist agency e.g. DACAS)



Withdrawal features


  • Insomnia

  • Headaches

  • Runny nose, watery eyes, yawning

  • Poor appetite, nausea, vomiting

  • Sweating, goosebumps, hot & cold flushes

  • Diarrhoea, abdominal cramps

  • Anxiety, agitation, restlessness

  • Tachycardia, elevated blood pressure

  • Cravings, strong desire to use

  • Muscle & joint pain

Although heroin withdrawal is unpleasant, it is not life threatening unless there is serious underlying disease.

Withdrawal symptoms generally start within 6-24 hours of last use and last about 5-7 days with a peak at 48-72 hours. The main physical symptoms subside but sleep disturbance and mood changes can persist for weeks, and the desire to use again for much longer. Hallucinations and seizures are not typical features of heroin withdrawal and should alert you to other causes or disorders.
3. MANAGEMENT

Supportive care





  • Offer written information, e.g. Turning Point’s “Getting through heroin withdrawal” booklet

  • Supportive counselling from the GP or other health worker (e.g. regional home based withdrawal worker)

  • 24-hour telephone counselling available from DirectLine (1800 888 236)



Nutrition & Fluids

Recommend that the patient:



  • Drinks plenty of fluids (e.g. 2-3 litres of water or fruit juice daily)

  • Avoids caffeine & alcohol.

(Cont)




  • Eats light & healthy meals (small meals several times a day are better than one big meal)


Medication



  • The following medications can provide symptomatic relief. If concerned re. compliance, organise daily pick up from pharmacy, or have medication supervised by a responsible adult.




  • Anti-emetic preparation (e.g. metoclopramide 10mg qid for up to 3 - 4 days)

  • Antidiarrhoeal preparation (e.g. atropine & diphenoxylate i - ii tab tds for up to 3 - 4 days)

  • Antispasmodic (e.g. hyoscine butylbromide 10-20 mg qid for up to 3 - 4 days)

  • Anti-inflammatory (e.g. ibuprofen 400 mg qid for up to a week)

  • Quinine 300 - 600 mg nocte for skeletal muscle cramps for 4 to 5 days

  • Benzodiazepines can be useful but are not usually required or recommended beyond 5 days.

  • If diazepam is prescribed use a reducing regime (e.g. diazepam up to 5mg qid for 3/7; then bd for 2/7 then nocte for 1/7);

  • Paracetamol -codeine preparations can alleviate symptoms, but prolongs the duration of withdrawal discomfort. If prescribed, use up to ii qid for 2/7 then ii tds for 2/7 then cease. Do not persist > 1 week




  • Monitor the patient regularly and adjust the medication and treatment plan according to the client’s response and level of drug use.

  • Withhold the medication if the patient is intoxicated


Drugs NOT recommended for outpatient heroin withdrawal: Antipsychotics; flunitrazepam; high dose clonidine (>900micrograms per day due to risk of hypotension and sedation)


Monitoring





  • Daily review is recommended by the GP or a suitable health worker (e.g. home based withdrawal worker).



Emergency plan





  • A plan needs to be made for dealing with complications which may arise, and include phone numbers for counselling support (eg withdrawal workers, Direct Line), the GP or locum cover, and ambulance.



Ongoing Plan





  • It is essential to WARN patients regarding overdose - decreased tolerance after even a short period of abstinence can lead to death if the same quantities of heroin are used as before. Mixing medications with alcohol or other drugs can also lead to overdose.




  • Training in relaxation techniques can be helpful in giving an alternative to reaching for drugs when anxious.




  • Withdrawal services can be a life saving intervention for some patients. However, on its own, withdrawal treatment is not associated with long term benefits. Ongoing participation in treatment is required to achieve long term changes. Consult with DIRECT Line regarding post withdrawal treatment options.



4. HARM MINIMISATION APPROACH


  • Discuss safe using, blood borne virus testing and vaccination




  • Discuss other treatment options if initial plan is unsuccessful (e.g. referral to methadone treatment, inpatient detox - DIRECT Line can assist with appropriate referrals)

This information is a general guide for the management of heroin withdrawal. Consultation with a specialist service (e.g. DACAS) is recommended for patients using multiple drugs or with serious medical or psychiatric conditions. The drug doses given are a guide only and should be adjusted to suit individuals.



For clinical consultation around the management of an alcohol or drug problem, ring DACAS on 1800 812 804, or ring DirectLine on 1800 888 236 for 24/7 telephone counselling, support and referral information

Last revised: 31/07/03 Page of


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