Time for better opioid detoxification strategies, researchers say

Addiction services must urgently consider the way they offer support for those wanting to come off opioid substitutes through detoxification, according to researchers at Imperial College London.

Following a review of relevant studies, they say different strategies are needed to better support individuals diagnosed with opioid dependence but who aspire to live an opioid-free life, if results are to improve.

Among their recommendations are specialist training for addiction services staff to manage opioid withdrawal during detoxification, better provision of medication to alleviate withdrawal symptoms, and more control by individuals over their own tapering (gradual withdrawal) process.

Other strategies they suggest include support from experienced peer support workers for people going through detoxification, and access to psychological support during the process. They also recommend increasing the availability of inpatient or residential settings for those without an appropriate home environment.

Amy Bagshaw at Imperial College London, the first author of the paper, said, “In our experience as an addiction research team, many people with opioid dependence do want to come off opioids and their substitutes completely, at some stage. But few people are managing to do this successfully every year. Having reviewed the evidence and the factors involved in successful withdrawal, we believe these steps could really help improve the present situation.”

She added, “Staff at addiction services may not be aware of how to adequately support individuals through the detoxification process, or how to approach the initial conversations.”

Globally, 16 million people have been diagnosed with opioid dependence, and there are more than 120,000 opioid overdose deaths a year. Patients can be treated with opioid substitution therapy, involving treatments like buprenorphine and methadone, sometimes coupled with psychosocial support. This has resulted in improved well-being and long-term stability for many patients.

While for many this is sufficient, and complete detoxification is often not recommended for people with addiction problems, many people decide they want to come off the substitute therapies completely. But withdrawal is notoriously challenging.

The researchers note that the number of individuals leaving their treatment “free of opioid dependence” in England has been falling over the last decade, from around 37% to around 23%.

The researchers in the Addiction team at Imperial College London reviewed existing research studies of individuals with a diagnosis of opioid dependence undergoing detoxification from substitution therapies, as well as staff responsible for providing the treatment.

Their systematic narrative review study, published today in Addiction journal, examined 41 research studies originating from the U.S. (22), UK (7), Sweden (6), as well as single papers from Canada, Ireland, Norway, Switzerland, Australia and China.

The medications explored across the studies included methadone (28), buprenorphine (5), both forms (6), and unspecified treatments (2).

The study found that key barriers to success included psychological challenges, such as fear of withdrawal, relapse and instability; low confidence or motivation; and physical challenges, including severe withdrawal symptoms during the dose taper.

Social, environmental and service-related factors strongly influenced outcomes, with unstable housing, negative social networks, and inadequate professional support all hindering detoxification. The researchers also highlight a lack of recommended medicines to alleviate the emergence of opioid withdrawal symptoms. These varied symptoms are currently treated with a mixture of benzodiazepines, antidepressants, antihistamines and anti-inflammatories. The only drug licensed to support multiple symptoms of opioid withdrawal, Lofexidine, is no longer available in the UK, although it is available in the United States.

Dr. Louise Paterson at Imperial College London’s Department of Brain Sciences said, “Detoxification from opioid substitutes is a difficult process to complete, but here we have found a clear roadmap to better treatment provision to support people who want to undertake it. In fact, many of these strategies are routine in alcohol detoxification pathways but less often present for opioid detoxification. Our recommendations should be urgently considered by addiction services to improve results for those who aspire to live an opioid-free life.”

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Gaby Clark

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Andrew Zinin

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