DETOXIFICATION AT THE STAPLEFORD
The Stapleford Centre pioneered rapid and humane withdrawal from opiates and alcohol. We were the first organisation in Britain to develop a supervised Naltrexone programme, for the management of heroin use and the first in the private sector to offer a supervised Antabuse programme for alcohol abusers.
WITHDRAWAL OR MAINTENANCE ON BUPRENORPHINE (SUBUTEX)
Burprenorphine is a rather unusual opiate, which is increasingly used for maintenance and withdrawal. It is not a new drug and under the name Temgesic, it was widely used for pain relief. It is still prescribed as Temgesic by only in the smallest tablet sizes - 0.2mg(=200mcg) and 0.4mg (= 400mcg). The larger tablets of 2mg, 4mg and 8mg have the trade name Subutex.
When buprenorphine was first introduced over 20 years ago, it was thought not to have much potential for abuse. The Scots soon disproved this and it became quite a problem north of the border though for some reason, it was never really popular further south in the UK.
The unusual feature of buprenorphine is that although it acts as an opiate and therefore has nearly all the effects of other opiates such as heroin, morphine, codeine, methadone etc., it also has some antagonist activity. This means, among other things, that it is very difficulty to overdose on buprenorphine because the antagonist activity is enough to stop the usual effect of opiate overdoses, which is to depress breathing so that the victim eventually dies from lack of oxygen. This feature has made buprenophine popular as a maintenance drug and it is the standard drug for this purpose in France. The built-in antagonist action can make buprenorphine a slightly tricky drug to get started on but provided that buprenorphine is started when you are in slight withdrawal - whether from heroin or methadone - there isn't usually much of a problem. However, if you give buprenorphine to people who are still taking their normal dose of heroin, morphine or methadone it can precipitate withdrawal, though the degree of withdrawal is usually quite mild.
Buprenorphine is a very long acting drug - even longer than methadone. It's possible to take a double or triple dose of buprenorphine every second or third day without getting much withdrawal. Another characteristic of buprenorphine is that it isn't well absorbed from the stomach. It has to be dissolved under the tongue and kept in the mouth for a few minutes and it is then absorbed directly though the mucous lining of the mouth. Like all opiates, it has a rather bitter tasted but because it is also a very potent drug, the total dose (and therefore the total bitterness) is quite low. Most people do not need more than 8-16mg a day.
Buprenorphine for detox
Buprenorphine seems to be the easiest opiate to withdraw from and the easiest one from which to make the transfer to naltrexone. This may be because it already has some antagonist activity, so that the move to naltrexone (which is pure antagonist) is less sudden. There are two ways to use buprenorphine in detox. One is to transfer to it from heroin, morphine or methadone about a week before starting detox, in the same way that we currently switch patients from methadone to morphine before detox.
The other technique seems useful for withdrawal as an out-patient. Before starting a reduction regime (tailored to the individual by our doctors), the patient should be in between 12-24 hours of withdrawal. This will facilitate getting on to buprenorphine without a reaction to the antagonist activity of the first small dose. Over the next 2-4 days the patient takes buprenorphine on a daily basis building the dose up before reducing it again over 10-21 days as far as 0.1 or 0.2 mg a day, if necessary. Four or five days after the patient's last dose of buprenorphine, he/she can usually swallow a whole tablet of naltrexone without much, if any reaction. Ideally, naltrexone can be started at home before the patient comes in for the insertion of a naltrexone implant.
Please Note: Following assessment for subutex detoxification, you will be required to return to the clinic 3-4 days later to assess your progress, and thereafter, at least every week until you are detoxed. This is regardless of where you live. If such attendance is an impossiblity then this treatment is not an option for you.
POST DETOX ADVICE July 2002
Now that you have got through the worst of the physical discomfort of opiate detox and have started on naltrexone by mouth or implant, you may have to work hard to stay opiate-free and to get into habits of thinking and behaving that don’t keep drugs (especially opiates) at or near the centre of your life. Some of you already have lives which are quite satisfying. If you have left illegal drug use behind and were on a regular methadone script for years, you may by now be a pretty average citizen doing pretty average things, except that you also took a cupful (or syringeful) of methadone every day. A surprising number of heroin addicts also lead fairly ordinary lives if they have enough legitimate income to pay for their habit as well as for ordinary living expenses and don’t have to mix too much with the drug underworld.
People in this group (ie. people who are employed or at least employable; people with mainly non-drug using friends and family; people who have hobbies other than smoking or injecting opiates) tend to do well after detox. They have to get used to feeling physically and mentally rather different but some people feel pretty good within a few days, stay that way and never look back. They may have the odd drink or joint but they never use opiates again and never again have a significant problem with any drug, legal or illegal. These people do exist but they are a lucky minority. Apart from a few sleeping tablets or perhaps some medication for diarrhoea or backache for the first week or two after detox, they need very little medical or psychological support.
At the other extreme, there are those who missed out on large chunks of their adolescence, never had any regular employment and have few prospects of finding legal work. Most of their life has centred around drug use, often involving the heavy use of drugs other than heroin. Most of their friends are similar. People like this are likely to find it hard to develop even a relatively drug-free lifestyle, though it’s not impossible. Some may manage to stop using heroin, but will continue or start to use other drugs heavily, including alcohol which, though legal, can be much more damaging than heroin in terms of health and behaviour.
Some people in this group get more or less drug-free for several months after detox only to discover that previous heavy drug use has shielded them from the emptiness of their lives or from areas of serious psychological conflict or disappointment. Drowning your sorrows – whether with alcohol or heroin – may sometimes work as a short-term approach but is not recommended as a regular tactic.
Relapse rates after detox vary a lot, partly depending on what sort of patients we are talking about. It is hardly surprising if research shows that people with jobs or job prospects and the support of families are less likely to relapse than those who have neither. Thirty year old addicts, who tend to be growing out of their addiction, do better than twenty year olds who may be growing into it.
How to improve your chances of doing well
‘Doing well’ doesn’t necessarily mean not using any mood altering drugs. If it did, we would have to regard any detoxified heroin addict who continued to smoke cigarettes as a failure. ‘Doing well’ can mean staying off all mood-altering drugs and obviously if you don’t use a drug, you can’t abuse it. However, it can also mean (and for many people it does mean) using mood-altering drugs in a way which doesn’t have any significant bad effects on your mood, behaviour, relationships and employability. For someone who has never had a problem with cannabis or alcohol, continuing to use these drugs after detox in the same way may not be an issue, though it may worry your friends and relations and will almost certainly worry your NA group, if you attend one regularly. On the other hand, getting completely ‘clean’ even for a few months can be a way of telling yourself and others that you really are taking your drug problem seriously. The choice is yours, but remember: if you don’t use, you can’t abuse.
There are really four stages in successful and lasting withdrawal from opiates. The first is getting through the worst of the acute withdrawal symptoms to the point where things start to improve rather than becoming worse day by day. With conventional detox programmes, many people don't even get to this stage, whereas with rapid methods we can virtually guarantee success. The second stage involves coping with the residual withdrawal symptoms which vary enormously in both duration and severity. Some people - but not many - are back at work in a day or two, feeling almost 100%. At the other end of the scale, some unfortunates still have troublesome symptoms - aches, sweating, shivering or diarrhoea - even after a month or two. And of course, most people find that it takes a long time for their sleep to return to anything like normal. The good news is that with appropriate prescribing, we can usually suppress these symptoms or keep them at tolerable levels. In the third stage, the symptoms have disappeared and it's a question of getting used to life without opiates. This may be easy or it may involve learning a whole new set of habits and responses. The fourth stage - at least a year down the line- implies that you have already learnt these new habits and are getting used to spending the next twenty or thirty years making them a routine and normal part of your behaviour.
Is regular naltrexone more important than regular counselling?
Most of the patients we detoxify don’t have serious underlying psychological or social problems. Or rather, most of the problems that they have are likely to be due to their heroin abuse and not the other way around. If they stop using heroin, most of their problems should disappear sooner rather than later unless they replace heroin with another drug problem. Until someone has been clean for two or three months and got over the residual withdrawal symptoms which in some people can be quite persistent, it is very difficult to know whether any particular problem is a pre-existing, underlying one or a temporary problem which will disappear once the patient has adapted to the physical and social changes that go with detoxification. Only time will tell, but what it seems to tell us is that most of our patients are not freaks or psychological cripples.
Taking naltrexone regularly maximises your chances that you will stay clean for long enough to get through this very crucial second stage of withdrawal. If you don’t get through this second stage, counselling isn't going to be very helpful because you will have relapsed and your self-esteem will have dropped a few more points. Taking naltrexone regularly – whether by mouth or implant – is a way of telling the world and yourself that you are serious about staying off heroin. So it is important for what it symbolises as well as for its practical protective effect.
What do we mean by counselling anyway?
Counselling seems to mean very different things to different people. Historically, a counsellor was someone who gave counsel – i.e. advice – to a king. Of course, kings could, and often did, ignore that ‘counsel’ but at least they had the benefit of hearing views which might be different from their own and which might be helpful. We are all supposed to be equal these days, so you too can ignore the advice of your counsellor, but getting advice or even information from someone who knows what they are talking about is usually not a complete waste of time.
Counselling can also mean simply talking and listening. In practice, this often means just bouncing a few ideas around with a sympathetic listener and getting things off your chest. Being a sympathetic listener means, among other things, giving someone time to talk and encouraging them to talk if they feel shy or are easily intimidated by authority figures. It also means developing the sort of relationship which enables the patient or client to trust the counsellor with sensitive information. Developing such a relationship can take time and as with ordinary human relationships, it may not happen if the chemistry or circumstances aren’t right. This sort of counselling involves discussing the changes - positive and negative - that come with being opiate-free, dealing with non-opiate drug use if necessary, work and relationships, and with any underlying psychological or psychiatric problems such as anxiety or lack of confidence.
Some patients (and some counsellors) are particularly interested in finding reasons for their use of drugs. In reality, this is often a pointless exercise since the reasons are usually fairly obvious. Most of our patients report being introduced to illegal drugs in the same way and for much the same reasons that they were introduced to legal ones like tobacco and alcohol. They liked experimenting with new things and were introduced by friends. Using a particular drug was often a way of showing solidarity with a particular social group (just as not using could be a way of identifying with a different type of group). Most people weren't feeling unhappy when they first used a particular drug. If they continued using it, it was generally because they liked the effects or because everyone else was doing it.
In some cases, people find that using a particular drug relieves feelings of unhappiness or tension and this can obviously make it more likely that the use of that drug will continue. However, the levels of unhappiness, tension or anxiety are not usually higher than those experienced by most people. The difference between people who drown their sorrows and people who don’t isn’t usually that they have bigger and better sorrows to drown. It's usually because they have got into the habit of drowning them while other people deal with similar sorrows in different and less damaging ways.
The fact that many of our patients don’t seem to have much more than their fair share of sorrows to drown shouldn’t blind us to the fact that quite a few have lives where there is much pain and little pleasure. Quite often, this depressing pattern started in early childhood. If people happen to have been brought up in a family where love, laughter, security and good rôle models were in short supply, if anything like a normal process of growing up was disrupted by a messy divorce, illness, death or alcoholism, repeated physical or sexual abuse, war or serious poverty, it is not surprising that some of them get into the habit of dulling their misery with chemicals.
With problems like these, there are no quick fixes except perhaps falling in love and living happily ever after (and preferably not with another addict). More usually, it means rebuilding if not the whole of your life, then at lease some important bits of it. It means having something reasonably interesting, and emotionally rewarding, to occupy your time, your hands and your brain, so that you can fill the big jagged hole where drugs used to be. Especially if you rather liked injecting them.
What is 'depression' and how do we deal with it?
There are two sorts of depression. By the far the most common is feeling depressed because of things that have happened (or haven't happened) that would make most people depressed. This can include events like bereavement, losing a job, not being promoted or your partner going off with someone else. This sort of depression could equally well be called 'understandable misery'. The other sort of depression happens without any very obvious reason or when the level of depression is out of all proportion to the events that have occurred. The distinction is important because anti-depressant drugs can be quite helpful in the second type but are less likely to be helpful in the first type, though they may still be worth a try. In the second type, there is quite often a family history of depression and periods of depression may have been present before drug use became a problem. Where appropriate, we are happy to prescribe anti-depressants or to refer you to your local psychiatric services, whichever is the more convenient.
Dealing with relapse
Relapse doesn't only happen to other people. It can happen to you and it probably will, but don't despair. First of all, relapses come in all shapes and sizes, from the short and trivial - a lapse rather than a relapse - to the prolonged and catastrophic. Of course, naltrexone stops relapses occurring in the first place but there are ways of stopping little lapses from becoming big relapses. These include not arguing yourself into believing that because your resistance wasn't quite as strong as you thought it was, you might as well go the whole hog and have a real blow-out. About two-thirds of all relapses during the first six months after withdrawal occur in the first six weeks. If you have never previously stayed opiate-free for more than two or three weeks in the real world, six weeks might seem quite a long time. Of course, breaking your previous abstinence record is always an achievement, but you probably shouldn't be thinking of opening the champagne until you can look back on at least six months. And not just six months of abstinence from opiates and the unproblematical use of other drugs but six months of improvement in those other areas of your life that we mentioned earlier. If you do get a habit again, think seriously about resuming methadone or morphine for a few weeks to limit the harm that relapse can cause.
How long should I be in treatment?
For most people, we feel that six months should be the absolute minimum. Naltrexone doesn't usually give much protection unless the tablets are supervised or you have a series of implants. However well you are doing, we would like to have a serious discussion around the end of the six months follow-up period so that we can decide, in discussion with you and your nearest and dearest, what level of treatment is needed during the next six to eighteen months. Some people should continue to take naltrexone or have naltrexone implants for a year or more. (Our current record holder has had naltrexone implants continuously for about two years now.)
One very useful trick is to agree to take even a quarter of a tablet of naltrexone dissolved in liquid in front of a family member, once a week after a decision that daily naltrexone or implants are no longer thought to be necessary. Swallowing this small weekly dose of naltrexone is rather like having a urine test for opiates. It demonstrates that you are still opiate-free (because otherwise you would risk a very unpleasant reaction and would therefore refuse to take the naltrexone) and it probably also acts as a deterrent against occasional opiate use. It is certainly much more dignified than a urine test. If the naltrexone is refused, it alerts your family to the fact that there may be problems. It is much easier to get people back onto naltrexone if they have only been using for two or three days than if they have been using for two or three weeks.
What about groups like NA?
A useful number of people find NA helpful and some become very involved with the organisation. For people lacking a sense of purpose in life, NA can sometimes provide one. Most of the treatments and techniques that we advise following detox seem to us to be entirely compatible with the principles of NA, especially naltrexone. Unfortunately, some NA groups can be very dogmatic and may be fundamentally opposed to any kind of medical treatment. AA (from which NA developed) originally encouraged good relations with doctors but lately, a pronounced anti-doctor and anti-medication attitude seems to have become common in most NA and AA groups.
'12-Step' groups like NA and AA (meaning the 12-steps in recovery which are the basis of the AA approach) are perhaps most helpful for people whose life has previously centred round drug taking and who have few non-drug related interests. Becoming involved with helping others can be very satisfying but it can also be very frustrating and depressing. On the debit side, many people in Britain are not comfortable with what is often seen typically as an American habit of talking about their feelings in public. Sometimes, this is because they don't like talking about their feelings in any setting, which may not be helpful for their recovery. Quite often it just seems to represent an understandable feeling that some things are basically private. People who try NA groups and then drop out are often made to feel quite guilty and told that they are bound to relapse. This is untrue and unhelpful. Another problem with NA groups is that they can attract bad as well as good influences. Many patients tell us that group members or hangers-on try to sell drugs and there is an understandable tendency for people who may have recently split up with a partner because of their drug problem to meet other recovering drug users, when both of them may be on the rebound. This is not usually a recipe for lasting happiness or abstinence.
Of course, there are plenty of ways of getting involved with a group which don't require attendance at NA or similar organisations. Most reasonable sized towns have a large range of courses and societies. If you feel too inhibited to even approach such organisations, you may benefit from social skills training which is quite widely available through the NHS in many areas. We can usually arrange a referral. Having a job that you like doing is a great help and is often another kind of 'group therapy'. If you don't like your job, doing a course is a good way of qualifying yourself to do something more interesting.
In 2003, we helped to set up London's first 'SMART Recovery' group. SMART groups, like AA, originated in the US. They have most of the advantages but fewer of the disadvantages associated with NA groups. They don't encourage guilt in non-attenders or advocate life-long membership and while valuing the constructive thoughts of the group's members, they are led by professionals. A SMART group meets weekly at the Stapleford Centre under the guidance of Paul Russell, an experienced counsellor. He can be contacted on 07986 935 280. The SMART website is at http://www.smartrecovery.org
What about rehab?
In our view, rehabs have three main functions. At their most basic, they offer accommodation and food to people who don't really have a place of their own and for whom it is difficult to provide help because they never stay in one place for long. Secondly, they provide a period of convalescence in the often difficult weeks after detox, away from family or friends who may themselves need a break. Thirdly, for people whose lives have been very badly messed up by drugs, who have no job and who have lost or nearly lost most of their important relationships, rehabs can provide a stable, structured and disciplined environment, ideally with suitably trained and sympathetic staff. The problem is that to benefit from this structure and discipline, people often need to stay in a rehab for several months and in practice only a small percentage do so. The drop out rate is very high - typically around 80% after six months. Recent British research suggests that in many respects, rehabs are not much better overall than methadone maintenance at helping opiate users stay out of trouble, but at a much greater cost in both money and in disruption in work and domestic life. For people without jobs, this may not matter but in general, anyone with a job should think very carefully before surrendering it or jeopardising it simply to go into a rehab.
And another important point. Whether run as charities or for profit, rehabs have high staffing and upkeep costs. Like hotels, if they don't keep their beds filled, they risk financial disaster. That is why rehabs rarely turn people away if they have empty beds. Worse, many rehabs offer only residential treatment and therefore cannot offer alternatives even if they are clearly indicated. Remember, there is nothing new about addiction. People have been getting over it - usually without professional help - throughout recorded history. Most people eventually grow out of their addiction in much the same way as most people grow out of juvenile delinquency. The trick is to stay alive long enough for this natural maturing and recovery process to occur. Addiction is a journey. We can be very helpful at particular points along the way but time is the great healer.
For further information or to make
an appointment please contact:
Toby Burton on +44 (0)20 7730 0680
or Reception on 020 7823 6840
(Please note: Our lines are often busy so, if you can't get through, please leave your name and number on the answer machine and we will get back to you.