Effective Treatment of Heroin Withdrawal in Corrections

Imagine this: You’re practicing medicine and a patient comes to you with an illness. You make the diagnosis and then say to the patient, “I can see that you are very sick. And there is a highly effective treatment for your condition that would make you feel a lot better. It’s simple and it isn’t even expensive. But, you know what? I’m not going to give it to you! You’re not sick enough. Come back tomorrow. If you’re sicker tomorrow—well, if you’re sick enough—I will treat you then. But not right now.”

Crazy, right? We’d never do such a thing.

But . . . the problem is, we frequently do that exact thing with our heroin withdrawal patients. I’m not singling out correctional medicine practitioners here. I think that, in general, heroin withdrawal is treated better in correctional settings than it is in the community. Nevertheless, it is a fact that heroin withdrawal is often not properly treated in jails and prisons. I have seen it.

I believe that there are four main reasons that some facilities do not appropriately treat heroin (and other opioid) withdrawal.

This is a Myth: Cold turkey withdrawal is not dangerous

The first is the belief that cold turkey withdrawal from heroin does not hurt anyone. I myself was taught in my residency “no one dies from opiate withdrawal.“ This is a very commonly held belief to this day.

The problem is that this is simply not true. It is a myth to believe that no one ever dies during withdrawal. People do.

Think of the situation of heroin withdrawal this way: No one disputes that patients can get very sick when going through heroin withdrawal. And maybe young and healthy patients can tolerate being that sick with no lasting problems. But what about someone who isn’t that healthy to begin with? Say someone who has asthma and heart disease? Or maybe they have an underlying sepsis acquired from sharing needles? What if this patient is also malnourished and dehydration from not eating? Could such a person already weakened by these conditions end up dying when the physiological stress of withdrawal is piled on? Of course they could!

And they do. I personally know of cases where patients did indeed die while going through opiate withdrawal. But even if they don’t, people get very sick from heroin withdrawal. To assume that opiate withdrawal is a benign condition is a serious fallacy.

Clonidine is an effective treatment for heroin withdrawal

The second reason that opioid withdrawal is often not treated is the mistaken belief that the only effective treatment is more opioids. And jail practitioners are reluctant to prescribe opioids for opioid withdrawal for various reasons.  I understand this.

But the belief that the only effective treatment for opioid withdrawal is more opioids is also a myth. There is indeed a highly effective non-narcotic treatment for opioid withdrawal: clonidine.

I should point out here that I am talking here about using clonidine as a short-term treatment for acute heroin withdrawal in a correctional facility. I am not talking about treating the underlying opioid addiction itself. The treatment of opioid addiction itself commonly uses long term prescriptions of Suboxone or methadone, known as Medication Assisted Treatment (MAT).

I am a big fan of addiction MAT (see my comments about continuing outpatient MAT in jails here), but, treating withdrawal is different than treating addiction. We are talking here about withdrawal, most commonly from heroin. When heroin addicts are booked into a jail for, say, a few days, it is simply not logistically possible get them enrolled into a MAT program. These patients are going to experience withdrawal. Let’s treat that first—using clonidine.

Clonidine has been validated as an effective treatment for opioid withdrawal in several studies. Here is the Cochrane Review of several of these.

I also have my experience of successfully treating literally hundreds of patients for opioid withdrawal with clonidine. I can tell you from long experience, it works and it works well.

I understand the reluctance to use opioids in a correctional facility for heroin withdrawal, but I do not understand any reluctance to use clonidine, especially since clonidine is now in common use as a treatment for all sorts of other conditions, such as PTSD and nightmares.

Don’t use Benadryl to treat heroin withdrawal!

The third reason that heroin withdrawal patients are not treated adequately for withdrawal is that some facilities use ineffective treatments such as diphenhydramine (Benadryl) or hydroxyzine (Vistaril).

Let me be simple and clear: hydroxyzine is not by itself an effective treatment for heroin withdrawal! There is no medical literature to support using hydroxyzine in this role.

And why would anyone prefer Benadryl over an effective medication like clonidine, anyway? One works, one doesn’t.  Benadryl is, at best, an adjunctive therapy. If you want to add Benadryl to a clonidine regimen for heroin withdrawal, I have no objection to that. Just don’t use Benadryl as the main therapeutic agent

A word about diarrhea. During heroin withdrawal, patients commonly have diarrhea and abdominal cramps. Many facilities treat this with loperamide. I also have no problem with the use of loperamide as an adjunctive therapy to clonidine, but since the cause of the diarrhea is withdrawal, a more effective treatment for the diarrhea would be to simply give more clonidine. Clonidine treats the underlying cause of the diarrhea. My opinion.  Also remember that loperamide has a high risk of abuse (as reported in this article).

COWS undertreats withdrawal

The final reason that heroin withdrawal is often not adequately treated is reliance on withdrawal scoring systems that require patients to meet a certain minimum symptom score before they qualify for treatment. A protocol found in Uptodate using the Clinical Opioid Withdrawal Score (COWS) (found here), for example, and does not begin treatment until a patient has a COWS score of at least 8. That means that a particular heroin withdrawal patient could present with anxiety, muscle aches, chills and nausea—and not get treated! We’re back to “Come back tomorrow and if you’re sick enough, I’ll treat you then!”

I suspect that scoring systems like this are modeled after the alcohol withdrawal scoring system CIWA, which also requires patients to hit a set minimum criteria of sickness before starting treatment. I do not understand this approach (I’ll address CIWA another day). We know that most patients who do not score very high initially are going to get worse. We also know that some patients are more stoic than others, and since they don’t complain enough, they will not get treated. And we know that the earlier that you begin treatment for withdrawal, the more effective it will be. So why wait?

Personally, if a patient in one of my jails says that he is a heroin user and is starting to feel sick, I will start that patient on clonidine. I don’t see the point of waiting. The clonidine will predictably make him feel better. And then he’ll be reassessed later to see if the clonidine dose is adequate or if he needs more.

A word about opinions

What I have written here is my own opinion. I arrived at this opinion as a result of my own training, experience and review of the medical literature. I believe that what I have written here is evidence-based and accurate. But I acknowledge that I could be wrong! You may disagree with me based on your training, your experience and your review of the medical literature.

But if you do disagree, please explain why, in comments.

How do you treat heroin withdrawal in your facility? Please comment.

11 thoughts on “Effective Treatment of Heroin Withdrawal in Corrections

  1. Charles Lee

    This and a previous article on Methadone are excellent articles on a very important and common issue. Please comment on treatment of the pregnant patient, both long term, short term and especially the one that comes in Friday night already on Methadone, but the Methadone clinic won’t be open until Monday.

    Reply
    1. Jeffrey Keller MD Post author

      Thanks, Charles. You are correct that pregnant women are a special case and should be continued on narcotics for the duration of the pregnancy, if possible. In the case you mention of a pregnant woman on methadone who arrives on a Friday night but her methadone clinic will not be open until Monday, The DEA allows you to legally treat her over the weekend. Here is a quote from the DEA website:

      Question: May an inmate enrolled in an NTP have methadone administered by Department of Corrections medical staff, if the facility does not have a separate registration as an NTP?

      Answer: Yes. Medical staff of the Department of Corrections may administer narcotic drugs to a person for the purpose of relieving acute withdrawal symptoms when necessary while arrangements are being made to have methadone supplied by the inmate’s NTP. A separate registration would not be required provided that no more than one day’s medication be administered to the person or for the person’s use at one time. Such treatment is limited to three days and may not be renewed or extended. [21 CFR 1306.07(b)].

      If your jail is licensed by the state and the DEA as a clinic, you can legally treat her yourself without an NTPO license for the duration of her pregnancy. However, few jails are registered as clinics. Here is the quote from the DEA website:

      Question: May a Department of Corrections medical staff administer methadone to incarcerated, pregnant, opioid dependent women during the course of their pregnancy without a separate registration as an NTP?

      Answer: Methadone may be administered in such circumstances when the following conditions are met. A practitioner, or authorized hospital staff, may administer or dispense narcotic drugs in a hospital to maintain or detoxify a person as an incidental adjunct to medical or surgical treatment of conditions other than addiction. Pregnancy is recognized as a medical condition by both DEA and FDA, and, therefore, this would be considered medical treatment of a condition other than addiction.

      Such medical treatment is allowed “in a hospital” or institutional setting. However, the Department of Corrections must be licensed by both the state and DEA as a clinic, a hospital, or a hospital/clinic. [21 CFR 1306.07(c)]

      Reply
  2. Charles Lee

    I read the Cochrane review on Clonidine and lofexidine. The conclusion was the Methadone was safer than Clonidine and lofexidine, and lofexidine had fewer side effects than clonidine. Yet your preference is clonidine. I’d appreciate it if you clarified. Thanks for an timely discussion.

    Reply
    1. Jeffrey Keller MD Post author

      Thanks for the question, Charles. Lofexidine is marketed in Great Britain as a treatment for opioid withdrawal, but is not available in the United States. As you say, methadone is a great treatment for heroin withdrawal. There are two major problems with using methadone in a jail (versus a supervised outpatient clinic). The first problem is that the DEA has strict rules for using methadone to treat the symptoms of acute withdrawal. Unless your jail is a registered Methadone Treatment Program (and very few are), it is too much of a logistical hassle for most jails.
      Second, and more importantly, jails do not know how long inmates withdrawing from heroin will be in jail. Many will only be there for a day or two. Methadone is a very long acting narcotic. Once you give it, it will hang around for days. The danger here is that an inmate gets out after, say, only one or two doses of methadone, uses heroin when the methadone is still on board, and this combination results in an overdose.
      Unless you can guarantee that a patient in jail will be there long enough to complete a withdrawal program and then transition into an addiction treatment program, it is safer to treat acute withdrawal with clonidine.

      Reply
    1. Jeffrey Keller MD Post author

      Lofexidine is marketed in Great Britain as a treatment for opioid withdrawal. It is not yet available in the United States.

      Reply
    1. Jeffrey Keller MD Post author

      Thanks for the question, Kristy. Since clonidine can lower blood pressure, it should not be used in patients with a very low blood pressure. Uptodate quotes a protocol that uses the blood pressure cutoff of 85/55. The Prescriber’s Letter recommends a cutoff of 90/60. It is quite rare to have a blood pressure that low. Interestingly, I think, clonidine is commonly prescribed as a nightmare therapy by mental health professionals who (I am told by patents) do not check a blood pressure prior to prescribing.

      Reply
  3. Dolph Druckman, MD, MPH

    First, thanks for provoking a needed discussion
    Second, may I suggest that the approach here not have a focus on “…what is best?” but what has greatest safety?
    What is best? can only be determined in retrospect, as the information we have or can likely rely upon in the detention setting is typically incomplete …
    My experience is within a center that has a liberal prescriptive landscape, including methadone for assisted “detox”… and our issues are on the opposite side and that is how do we insure patient safety.
    So I would respectfully change your opening question to: How is withdrawal handled safely, particularly when there may be multiple withdrawal “risks”…… Conservative care may be the safest, particularly when considering how many providers prescribe multiple medications for only “risks”….

    Reply
  4. Roger S Buck MD

    No discussion can be complete on this subject without mentioning Buprenorphine (Subutex). Maybe I missed it in Jeff’s article and the subsequent comments. I heard Todd Wilcox’s presentation on this at the ACCP Spring educational Conference March 18, 2017, Atlanta.

    Reply
  5. C. Hsien Chiang MD

    I agree that in general opioid detox is undertreated, and there’s wide misconception on use of Clonidine. My providers have not used it even though it is an option on our protocol due to BP concerns.
    A comment on Buprenorphine: We taper Benzo during Benzo detox, I’m not sure why we don’t taper Opioids (using partial agonist such as Bupernorphine) during Opioid detox. We already use it for pregnant women, and plan to use this in our detox protocols.

    Reply

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