Volume 3 Issue 5 May, 2013
Opioids like naturally occurring opium, semi-synthetic heroine and pure synthetics such as fentanyl and methadone are a commonly abused class of substances that activate receptors like μ(mu), κ(kappa) and δ(delta) found mostly in the brain, spinal cord and gut (Goodman et al, 2001). People though initially derive pleasure and intoxication out of opioid use but soon develop craving and withdrawal symptoms. As per International Classification of Diseases (ICD-10) this cluster of physiological, behavioural and cognitive phenomena constitutes the opioid dependence syndrome (WHO, 1992). Sustained opioid dependence is associated with several negative outcomes, including early mortality, increased rates of hepatitis, human immunodeficiency virus (HIV) infection, sexually transmitted diseases, and other health problems, as well as criminal justice system involvement (Sadock, Sadock & Ruiz, 2009).
A proper treatment would involve detailed history, medical and psychiatric assessment particularly keeping in view the physical social, psychological, financial, familial, occupational and legal consequences. Among the psychiatric co-morbidities patients often have mood disorder, psychotic disorder and personality disorders. Often patients particularly (injection drug users, IDUs) require detailed investigations for the medical problems (Galanter & Kleber, 2008). The goals of treatment of opioid dependence can be either harm reduction or abstinence and subsequent rehabilitation. Depending upon motivational status harm reduction (e.g. needle exchange programme for hardcore IDUs) may be practiced. Those patients desirous of complete abstinence require detoxification whereby they are treated for troublesome withdrawal symptoms by less harmful opioids having significant cross-tolerance, longer half-life and higher potency. Commonly used are methadone (μ receptor agonist- not available in India) and buprenorphine (partial μ agonist and weak antagonist at k receptor which is not widely available in India). So, other less effective though commonly used are dextropropoxyphene (DPP) and tramadol. For symptomatic use ibuprofen or other NSAIDS (for analgesia), clonidine, an alpha 2 agonist (for reducing sympathetic over activity) and benzodiazepines (for sleep and reducing anxiety) can be used ( Ruiz & Strain, 2011).
Since opioid dependence shares a prolonged relapsing and remitting type of course as in chronic medical illnesses like diabetes and hypertension, long term maintenance treatment is essential for abstinence. Agonist maintenance is done with methadone (Not in India) and buprenorphine (some centers in India). Antagonist maintenance with naltrexone is also a useful treatment though less effective particularly for the heavy users (Dhawan & Jhanjee, 2007).
Apart from pharmacotherapy, psycho-social interventions like motivation enhancement, and relapse prevention therapy can be useful. Patients also derive benefit from self-help groups like narcotics anonymous (NA), family and network therapy or by joining therapeutic communities (Lal, 2005). Only a holistic approach with comprehensive long-term therapy involving both pharmacological and non-pharmacological measures can effectively reduce the scourge of opioid dependence.
By Dr Aniruddha Basu MD, Consultant Psychiatrist, Postgraduate Institute Medical Science, Rohtak, Haryana
