Opioid Dependence

Opioid dependence: a serious, chronic, and relapsing disease.^1,2

Opioids are among the top 4 llicit drugs used in Australia.^3,4

Opioids include heroin and more commonly prescription opioids codeine, morphine, buprenorphine, methadone, oxycodone, fentanyl, pethidine, and tramadol.^3,4

Opioids alter how the brain works, hijacking the motivation and rewards processes - increasing the risk of dependence and making it extremely hard to quit.⁵

One in 4 people who use heroin will become dependent.⁵

Harms associated with opioid use

Almost 1 in 5 people detained by police in Australia (18%) tested positive for opioids.⁶

In Australia, people who use opioids are more likely to experience homelessness versus those with other substance use problems.⁷

Long-term use of opioids have significant health consequences, including:⁵

Tooth decay (from lack of saliva)
Irregular menstrual periods (females)
Impotence (males)
Memory impairment
Mental health issues including depression

Blood borne infectious diseases, e.g. HIV, hepatitis B and C
Liver and kidney diseases
Lung complications
Vein damage

In Australia, opioids were involved in 53.6% of unintentional overdose deaths in 2019.⁸

In Australia, more people die each year from overdoses involving opioids than from car accidents.^8,9

Help stop the stigma

Stigma is a barrier to treatment.¹⁸

The experience of stigma is associated with delays in seeking treatment, increased rates of treatment withdrawal, withholding information in an effort to avoid sub-standard care, as well as increased engagement in risky behaviour such as needle sharing.¹⁸

Fear of being stigmatised is also a key barrier for carrying naloxone, and can lead to injecting drug users distancing themselves from harm reduction services such as syringe exchanges.¹⁸

The following are tips for reducing stigma in everyday conversations:¹⁹

use person-centred language that focuses on the person, not their substance use
correct others who may have misconceptions about alcohol and other drug use or people who use alcohol and other drugs (AOD)
show support by treating people with dignity and respect
use non-stigmatising language that encourages people to seek help
don’t use stigmatising words like ‘addict’ that can hurt, damaging self- image and stand in the way of recovery. Instead talk about a person with dependence
focus on hope. When you empathise, you begin to see how words like ‘abuse’, ‘relapse’, ‘non-compliant’, and ‘dependent’ may come across like a prison sentence: hurtful, demeaning, pessimistic and hopeless
be aware of negative stereotyping – many people who use AOD feel threatened by the prejudice that results from misconceptions about AOD use
be an active listener. Acknowledge what the person is saying – don’t brush it off
use body language that shows you are there for them, let them know they are not alone, and their issue is important.

Treatment goals: minimising harm¹⁰

Treatment for opioid dependence in Australia is based on the principles of harm minimisation.

Goals of treatment include reducing demand and by extension the harms associated with use and improving quality of life.

Treating the person²

No one option works for everyone, and people with opioid dependence often go through a cycle of treatment, lapses and relapses into use. All available treatments should be considered in consultation with the person, taking into account their individual circumstances and preferences.

Treating the person²

Antagonist treatment
Counseling and psychosocial support
Detoxification (facilitated withdrawal)
'Rehab' programs
Substitution treatment: daily, weekly, or monthly

There are now more options for medication assisted treatments expanding options for how treatment is delivered – this means greater choice and a better chance that people will find options that work for them.^11,12

Psychosocial support^2,13

Psychosocial support is critical regardless of the form of treatment a person chooses. A person who is using drugs, including prescription drugs, may have reduced opportunities to engage in ‘normal’ life, including relationships, employment, or accommodation. Therefore it is important that the treatment plan is holistic and involves key services.

Counselling and psychosocial support, including self-help groups, are important components of relapse prevention. Psychological interventions help people to identify and address the reasons for drug use, the negative consequences of drug use, and the benefits associated with changing drug dependancy behaviours.

Detoxification (‘Detox’)²

Detox refers to a process of facilitated physical withdrawal from opioids. It is generally not considered to be a standalone treatment, but an entry point to opioid-free treatments. Detox includes:

Abrupt cessation with symptom management using non-opioid drugs OR
Tapering, involving a short course (usually less than 1 month) of reducing doses of an opioid substitution treatment.

Detox can be completed as an inpatient, or for those with sufficient support, as an outpatient.

For people that are highly motivated, with a stable support network and who do not have health conditions that may be affected by detox (e.g. chronic pain, mental health issues), these programs can provide an effective means of recovering from dependence.^10-12 Clients with complex needs may require a specialised detox program.

Rehabilitation ‘rehab’ programs²

There are a variety of different rehabilitation programs – short (week) vs long-term (12 months) residential, and outpatient day programs. Rehabilitation programs aim to provide a structured drug-free setting to address the underlying causes of addictive behaviour. These programs assist people to develop appropriate skills and attitudes to make positive changes towards a dependence-free lifestyle. Arrangements for ongoing support post-discharge are important for long-term success.

Antagonist treatment²

Opioid antagonist treatment is a medication used to block the effects of opioids. It is used as part of a maintenance program for people who have stopped using opioids Psychosocial support is an integral component of maintenance treatment.

Considerations

Has detox been tried before? If so, have circumstances changed that may increase success?
Are there other health conditions present that may be affected by detoxing (e.g. chronic pain)?
Is there a stable and strong support network available?

Substitution treatments²

Substitution treatment involves the prescription of a drug with similar properties to the drug of dependence, but with a lower degree of risk. Substitution treatment enables people to reduce their exposure to risk behaviours while stabilising their health and social functioning before dealing with the physical aspects of dependence.

Substitution treatment is widely available and helps to reduce opioid use, decrease deaths, and improve quality of life. Each treatment has advantages and limitations, but all require a prescription, and can prolong the process of withdrawal when discontinued.

Daily treatments

Daily opioid substitution treatment (includes treatments like methadone and sublingual bupenorphine) is effective in controlling cravings and symptoms of withdrawal. Additional benefits include regular and consistent contact with the treatment team and the control of being able to decide when and if to take treatment.^2,13 For some people, it has limitations:

Clinic locations and/or dosing hours that are difficult to attend can be a barrier to ongoing maintenance.¹⁴
Daily reminders of dependance.¹⁵
Stigma of daily treatment can undermine satisfaction and compliance.^14,15

Daily treatment formulations are also associated with a high risk of diversion both in the community, and in custodial settings as well.^13,14

Weekly and monthly long-acting injectable treatments

Weekly and monthly long acting injectable bupenorphine (LAIB) formulations are now available. They have been developed to provide the same benefits of daily treatment, while addressing the limitations, including daily reminders of dependance, stigma, and diversion.¹⁰ Long-acting injectable formulations also have limitations and may not be suitable for everyone, including:¹³

Less frequent contact with the healthcare team
Lack of day-to-day control over when / if to take treatment

Considerations

Has a substitution treatment been tried before? If so, is it worth considering a different approach?
How important is frequent contact with a healthcare provider?
How important are travel, privacy, convenience, and storing medications? (e.g. protecting a child’s accidental access of the medication, or protecting the misappropriation of medication from their surrounding social networks).

References:

Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1(1):13-20. doi:10.1151/spp021113.
National Guidelines for Medication-Assisted Treatment of Opioid Dependence, 2014. Accessed October 2022 <https://www.health.gov.au/resources/publications/national-guidelines-for-medication-assisted-treatment-of-opioid-dependence>
Australian Institute of Health and Welfare (2021) Alcohol, tobacco & other drugs in Australia., AIHW, Australian Government. Accessed October 2022 <https://www.aihw.gov.au/reports/illicit-use-of-drugs/illicit-drug-use>
Australian Institute of Health and Welfare 2018. Australia's health 2018. Australia's health series no. 16. AUS 221. Canberra: AIHW.
National Drug and Alcohol Research Centre. Heroine, What You Need To know, 2018.
Australian Institute of Health and Welfare (2021) Alcohol, tobacco & other drugs in Australia, AIHW, Australian Government. Accessed October 2022. <https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-otherdrugs-australia/contents/priority-populations/people-incontact-with-the-criminal-justice-system#illicitdruguse>
Australian Institute of Health and Welfare (2021) Alcohol, tobacco & other drugs in Australia, AIHW, Australian Government. Accessed October 2022 https://www.aihw.gov.au/reports/phe/221/alcohol-tobacco-other-drugs-australia/contents/population-groups-ofinterest/homeless-people
Penington Institute (2021). Australia's Annual Overdose Report 2021. Melbourne: Penington Institute.
Australian Road Deaths database. Accessed October 2022 <https://www.bitre.gov.au/statistics/safety/fatal_road_crash_database>
Commonwealth of Australia Department of Health 2017. National Drug Strategy 2017-2026. Publications Number: 11814. Accessed October 2022 <https://www.health.gov.au/sites/default/files/national-drug-strategy-2017-2026.pdf>
NSW Health. About alcohol and other drugs. Accessed October 2022 <https://www.health.nsw.gov.au/aod/Pages/about-treatment.aspx>
NSW Health. Withdrawal management and residential rehabilitation services. Accessed October 2022 <https://www.health.nsw.gov.au/aod/Pages/wmrs-contact.aspx>
NSW Clinical Guidelines: Treatment of Opioid Dependence, 2018. Accessed October 2022 <https://www.health.nsw.gov.au/aod/Publications/nsw-clinical-guidelines-opioid.pdf>
Benyamina A. Heroin Addict Relat Clin Probl. 2012; 14(4): 65-80.
Tompkins CNE, Neale J and Strang J. Substance Abuse Treatment. 2019; 104: 64-71.
Dunlop AJ, White B, Roberts J, et al. Addiction 2021.
Barnett A, Savic M, Lintzeris N, et al. Drug and Alcohol Dependence (2021), doi: https://doi.org/10.1016/j.drugalcdep.2021.108959.
Cheetham A, Picco L, Barnett A, Lubman DI, Nielsen S. Subst Abuse Rehabil. 2022;13:1-12.
Alcohol and Drug Foundation, Stigma - why words matter, April 2021. Accessed October 2022 <https://adf.org.au/insights/stigma-why-words-matter/>