Treating Heroin Withdrawal: Methadone, Suboxone and . . . Tramadol?

In my last JailMedicine post, I wrote that clonidine is an excellent drug for the treatment of opioid withdrawal. In response, several people have asked about methadone and Suboxone. Why not use one of those drugs instead of clonidine?

The short answer is that both methadone and Suboxone are excellent drugs for the treatment of withdrawal. However, both are much more complicated to use in jails due to DEA legal requirements and a much larger potential for diversion and abuse. If you are using Suboxone or methadone, great! I believe that clonidine is a better choice for most jails. Those interested in using methadone or Suboxone need to be fully aware of the DEA laws surrounding their use. Before you use one of these drugs, you must make sure that you are following the law. I know of two physicians in my hometown who were disciplined by the DEA for prescribing narcotics to treat addiction without registering. The DEA are not kidders!

By the way, Jail practitioners should also be aware that Tramadol has been used successfully to treat withdrawal, as well.

DEA laws governing methadone

The DEA laws governing methadone administration are complicated. In order to give methadone or any other schedule II narcotic to a patient for treatment of opioid addiction, you must register with the DEA as a narcotic treatment program. In general, if you are not formally registered as a narcotic treatment program and you give methadone (or any other schedule II narcotic) to treat addiction, you have broken the law.

However, there is one exception to this law, known as the “Three Day Rule:” The Three Day Rule says that a practitioner may give methadone for the treatment of acute opioid withdrawal without being registered as a narcotic treatment program as long as the practitioner follows these rules:

1. You may give the methadone for up to 72 hours
2. The 72 hour deadline may NOT be renewed or extended
3. You may prescribe no more than one days’ worth of methadone at a time
4. Alternatively, you can administer the methadone from stock
5. You must arrange for the patient to enter a registered narcotic treatment program.
(An excellent summary of these laws is found here).

Logistically, it would be very hard—bordering on impossible—to strictly adhere to these rules in most jails. Remember that big jails (more than 1,000 inmates) are uncommon. Most jails are in small communities, and most of those communities do not even have any registered narcotic treatment program in town at all.

The other problem with using methadone to treat heroin withdrawal preparatory to the patient joining a methadone treatment program is that many addicts cannot afford to pay for an outpatient methadone program once they get out of jail. Many would not be interested in such a program even if they could afford it.

Add to this the time and trouble it takes to properly stock a schedule II narcotic like methadone in a jail, and in my mind, the liabilities outweigh the benefits–especially when there are other good options for treating heroin withdrawal available without these drawbacks.

And remember that these rules apply not just to methadone, but to all DEA schedule II narcotics, including hydrocodone and oxycodone.

DEA laws governing Suboxone

Suboxone is definitely easier to use to treat withdrawal than is methadone. Suboxone is a DEA schedule III drug and one that the DEA has specifically authorized for the treatment of withdrawal and addiction. The DEA rules regarding its use are not as strict.

In order to use Suboxone to treat withdrawal, a prescriber needs to register with the DEA, take mandatory training (8-24 hours, depending on the certification) and then obtain what is called an “DEA-X” number, which must be used for each prescription. Prior to July of 2016, only physicians were allowed to write these prescriptions, but thanks to the Comprehensive Addiction and Recovery Act, now Nurse Practitioners and Physician Assistants may also qualify to write Suboxone prescriptions. NPs and PAs must complete 24 hours of training and, in most states, be supervised by a physician who also has a buprenorphine waiver. PAs and NPs may only treat 30 patients a year, however. The American Society of Addiction Medicine has summarized this law pertaining to midlevels here.

If you decide to get your DEA-X license to use Suboxone in your jail, you need to also be aware of some other potential drawbacks to the use of Suboxone in a correctional institution.

First, Suboxone is has huge desirability as a drug of abuse. If you prescribe Suboxone, you will inevitably have to deal with drug seeking, diversion and all of the hassles that this entails. This is not a small problem for many prisons and jails that use Suboxone.

Second is the “overlap” factor. Who treats patients in withdrawal when the person with the DEA-X number is on vacation or sick? Via the Principle of Fairness, it is not appropriate to treat patients on some days but not on others. This limits the utility of Suboxone to jails big enough to have multiple prescribers, who all have DEA waivers and who cover for each other. It is not going to work in a smaller jail where a practitioner is only scheduled once a week or an even smaller jail where the deputies pass meds!

Finally, there is the “are you sick enough?” factor. Since Suboxone is a precious commodity that causes high levels of drug seeking, most practitioners don’t prescribe it to everyone who says “I am withdrawing from heroin” while looking at them expectantly. Most require some minimum score on a suitable withdrawal scoring system like COWS.

What this means, however, is that some patients who are legitimately withdrawing from heroin are not going to get treated initially until they get sick enough.

Tramadol for Opioid withdrawal?

One of my favorite CME programs is Primary Care Rap (I should say here that I am not affiliated with this program–I just like it). The September, 2016 edition contained a segment on opioid detox strategies. The addiction specialist being interviewed, Ken Starr, M.D., described using Tramadol to treat acute opioid withdrawal with a five day taper as follows:

Day one: 100mg po QID
Day two: 100mg po TID
Day three: 50mg po TID
Day four: 50mg po BID
Day five: 50mg po once

Tramadol is not a pure opioid but one of its metabolites binds to the opioid receptor, and so can alleviate withdrawal symptoms. It has the advantage of being DEA schedule IV and so does not have the same restrictions and requirements as does methadone and Suboxone.

Primary Care Rap is a subscription service, but for those with enough interest, this episode can be found here.

Hot-off-the-press! A new study that supports the concept of using Tramadol to treat opioid withdrawal can be found here.

Back to Clonidine

I discussed my preference for clonidine in my last post. Let me again briefly summarize the advantages of clonidine:

1. Clonidine has the advantage of not being a controlled substance and so has no DEA legal restrictions.
2. It can be stocked and stored with other uncontrolled drug stock.
3. It has mild abuse potential (especially compared with any of the above competitors). Heroin addicts who have been to the jail before will ask for it when they come in again (because it works) but it does not nearly cause the security problems of the controlled substances.
4. Because of this, I have no problem giving the first dose of clonidine to heroin users who do not yet score highly on a withdrawal scale. In fact, I’ll sometimes give the first dose simply based on a reported history of heroin use, without any symptomatology yet.
5. Because of these points, clonidine can be used at about any sized jail, from the jumbo jails all the way down to little ten-bed jails.
6. Clonidine is effective. Patients may prefer narcotics but if the goal is to get a patient through withdrawal safely, clonidine works just fine.
7. If you are a Suboxone jail, you can use clonidine in addition to Suboxone. There is no law that says you have to use one or the other. Ken Starr in his Primary Care Rap presentation recommends doing this.

The final point that I want to make before leaving this topic is this: All of these treatments are better than no treatment. Cold Turkey withdrawal from heroin is dangerous and cruel. These patients are sick. You have multiple therapeutic options available. Pick one and treat them!

Once again, what I have written here is my own opinion, based on my experience and research.  Feel free to disagree.  I could be wrong!

What do you use in your jail to treat heroin withdrawal? I am especially interested in what is done in smaller jails, less than 200 inmates. Please comment!

11 thoughts on “Treating Heroin Withdrawal: Methadone, Suboxone and . . . Tramadol?

  1. Patty Workman NP

    I recently retired from a regional jail in Charlottesville, VA where treating various opiate withdrawals was a daily activity. We had a protocol that used clonidine and it was EXTREMELY successful. Other meds to treat other symptoms such as nausea and diarrhea and muscle aches were also part of the protocol.
    All patients going through withdrawal were kept in our medical housing unit for observation, this worked to reduce our patients’ anxiety and seemed to lessen their symptoms all by itself.
    I have had a significant number of people stop me on the street during these years to thank me for their treatment at the jail and for the chance at sober living it gave them. A little genuine concern goes such a long way..
    (For this and other reasons, I am opposed to using drugs like methadone and Suboxone for withdrawal. It is just prolonging the active addiction and the horrible consequences to the person’s life.)

    Reply
    1. Jeffrey Keller MD Post author

      Thanks, Patty! I agree that clonidine is very effective in treating opioid withdrawal.

      Reply
  2. Bruce Trigg

    The only problem with this approach is that it simply doesn’t treat the underlying disease. It would lbe like treating someone with a diabetic coma and not offering them insulin afterwards. Detox is not the treatment of opioid addiction; methadone and buprenorphine are the proven treatments. They are the standard of care in the community and therefore they should be used in jails and prisons of any size. There are many studies showing that people started on these meds in jail, or before release, are more likely to stick with treatment in the community, less likely to relapse, to overdose and to return to criminal activities. There are indeed complexities about how to do this but with half a million overdose deaths in the past 15 years, this is a human and health crisis. Every major public health issue is complex but must tackled. Communities can set up systems of care where the treatment is started inside the jail and then care is continued after release. It isn’t rocket science to set up such programs and they are happening in a number of places now.
    The recent media coverage (NPR, New York Times, ProPublica (https://www.propublica.org/article/vivitrol-opiate-crisis-and-criminal-justice) of how Alkermes has managed to get their unproven and overpriced product – Vivitrol – into hundreds of jails by influencing Drug Courts and politicians, makes it more important than ever for medical professionals who work in these settings to understand that the evidence for Opioid Agonist Treatments – methadone and buprenorphine – is overwhelming (and it doesn’t simply continue addiction; they are the treatments for addiction – the nicotine patches of opiate addiction) and should be implemented to save lives. I would be happy to provide references if anyone is interested to support this.

    Reply
    1. Jeffrey Keller MD Post author

      Hi Bruce,

      Like you, I am a strong advocate of MAT for addiction (meaning long term methadone or buprenorphine therapy). However, we seem to be talking about two different things. In my last two articles, I was addressing acute opioid withdrawal. Because of the opioid crisis, there is also a crisis of patients going through acute withdrawal in our jails. I want all of those patients to be treated appropriately for withdrawal and NOT allowed to go through withdrawal cold turkey. You agree with that goal, don’t you?

      After the acute withdrawal phase, I also would like to get each and every one of these patients into some type of MAT treatment program. No need for further references, I am already a believer! However, it is not possible to enroll all of these patients into a treatment program. Why? Three reasons:

      1. Not all communities have a MAT program available. The bigger cities do, of course, but not all of the small towns across the US. They all have a jail, and so will have inmates go through withdrawal, but many will not have a treatment program within a hundred miles.
      2. Not all patients want MAT when it is offered to them. I myself have tried to enroll inmates into a local MAT program before their upcoming release and have been told “Not interested.”
      3. One reason that addicted patients cannot or do not enroll in available MAT programs is that they cannot afford them. One of many problems with our current health system is that many patients who have the greatest need for medical services have no way of paying for it. Until we get some sort of broad public funding for addiction treatment, many addicts will not get treatment.

      For these three reasons, MAT for each and every opioid addicted patient is not an attainable goal at the present time. However, appropriate treatment for each and every acute opioid withdrawal patient in jail IS an attainable goal. Every jail can treat withdrawal properly, no matter how small.

      Reply
      1. Bruce Trigg

        Hi Jeffrey, Thanks for your reply. I don’t completely agree. Opioids are the best treatments for withdrawal. This is well studied. Using a buprenorphine taper of 3 to 5 days is very comfortable and even if it can’t be continued for the reasons you mention, it at least allows the patient to experience how they do feel on this medication so in the future they can seek out this treatment. So it really kills two birds with one stone.
        I lived in New Mexico for many years and we had thousands of people who received a five day bupe taper at a large county detox facility. And a provider doesn’t even have to be waivered to provide a three day taper of bupe. But with an almost 100% relapse rate after detox, it really makes sense especially given the epidemic we are now in and the billions of dollars for opioid treatment pouring into the states, to develop systems linking treatment from the jail to the community. In NY, where I live now, the state Dept of Health is doing free buprenorphine waiver trainings, now available to docs, PA and NPs, in communities that would like to provide bupe inside or pre-release in their jails but dont’ have the referral sources in the community. It really isn’t that complicated if a community wants to address the high recidivism and relapse among opioid users.
        I agree with you that how to pay for MAT treatment after release is still a big problem in many places, but even if the county govt paid for it out of probation and parole monies for example,, it would be far cheaper for any county govt than re-arrests, police, courts, jailing, parole and probation, drug courts, ambulances, ER visits, hospitalizations, criminal activity, etc that these folks cost the public coffers. These are very expensive people and treatment with MAT is cheap in comparison. In states that have expanded Medicaid (what state are you in?) , many, but not all, pay for methadone and/or bupe. FQHCs in other states may provide buprenorphine treatment as part of their primary care services on a sliding scale.
        By the way, when I was seeing patients, I prescribed quite a bit of clonidine in my addiction practice to patients who were on buprenorphine treatment but who continued to have cravings for opiates. I can send you a paper where I learned about this. It works quite well in my experience.
        I’m pleased that you are supportive of MAT in correctional settings. I’ve been working on this issue for at least a decade. I helped to start a methadone maintenance program at the Bernalillo County Metropolitan Detention Center in Albuquerque when I worked with the Dept of Health. For 11 years now it has provided methadone (free of charge – state and county govt are paying) to inmates who were on treatment at the time of their arrest. Now the county is finally moving towards doing methadone inductions and will probably start doing them soon.
        A local methadone clinic in Albuquerque has the contract with the county jall to provide the methadone treatment. So they have the licenses required to run the methadone program at the jail.
        One more thing; did you happen to see the news stories a couple of weeks ago about Vivitrol? It is being heavily promoted, you may be aware, for use in jails and Drug Courts despite a disturbing lack of evidence, concerns about overdose deaths after discontinuation, and due to heavy promotion by its maker, Alkermes, using what I think are corrupt practices such as paying politicians. I attach the links to these articles. I hope you will alert your readers to this scandal.
        All the best, Bruce
        1-
        http://www.npr.org/sections/health-shots/2017/06/12/523774660/a-drugmaker-tries-to-cash-in-on-the-opioid-epidemic-one-state-law-at-a-time
        2-https://www.nytimes.com/2017/06/11/health/vivitrol-drug-opioid-addiction.html
        3-
        https://www.nytimes.com/2017/06/18/opinion/opioid-epidemic-law-enforcement.html
        4-
        https://www.propublica.org/article/vivitrol-opiate-crisis-and-criminal-justice
        5-
        https://www.statnews.com/2017/06/29/vivitrol-methadone-opioids/

        Reply
        1. Jeffrey Keller MD Post author

          Good post, Bruce. I can’t say I disagree with you in general. But I think everyone in withdrawal should be treated. Many jails do not/will not use buprenorphine. Whether their reasons are legitimate or not, I want to point out that such jails should not let patients go through withdrawal cold-turkey. If they are not going to use buprenorphine, they should treat with something–and that something should be clonidine. I also have a problem with jails that use buprenorphine, but require patients to reach a certain level of sickness before they qualify. I think they should use clonidine on those patients who, in their systems, do not qualify for buprenorphine.
          As to Vivitrol, I am not a big fan. That may be a good topic for a future post!

          Reply
    1. Jeffrey Keller MD Post author

      Hi Andrew! Assuming that the patient is not too sick and has a blood pressure over 100 systolic, I usually start with clonidine 0.1mg po BID for ten doses. Then the patient will be reassessed. If the patient is doing well,that may be all that is needed. Some patients need more than this, though. Depending on how well they are doing, we will use clonidine o.2mg BID or even TID. If we use the bigger doses, we will taper over a couple of days at the end.

      Reply
  3. Adam Harley Gough

    In N. Ireland inmates who were on treatment at the time of their arrest usually get treated with the same dose of Methadone or Bupe while inside serving sentences of 3 months and up.

    In the usually relatively small jailing facilities around the country that are housed within the actual police stations and serve as custody suite short stay facilities before bail or court attendance and so actual sentencing prior to the serving of time in prison, persons who at the time of arrest are on Bupe or Methadone usually, and if they’re lucky enough and whose medical conditions are properly understood and attended to appropriately enough by the in-house doctor(s), who make short daily assessments, Dihydrocodeine is used to quell the withdrawal along with a low dose of Diazepam and/or Zopiclone as extra reinforcement meds and a sleeping aid if needs be.
    The Dihydrocodeine is usually dosed usually using between 3-5 tablets of the DF118 Forte®40 mg as standard.
    Being that these pre-sentencing/Court Appearance/ Bailed arrestees are only held within these small jailing facilities for 5 days or less this seems to be generally enough to hold any Bupe or Methadone patient comfortably enough, if not in fact a bit of a surprise blessing for most, who I tend to think , and expected myself, to in fact receive nothing – such is the lack of knowledge surrounding what is available and what can and should be given or at what dosage and how often must a person be attended to and redosed to best match their current Bupe/ Methadone regime.
    There is a general lack of understanding, care and observing of a strict and concise practice that should be carried out with continuity and the exact same attentiveness and with the exact same regulations throughout all police stations in the country.
    Heroin and opiate use and abuse in general has not been a problem in the country for long enough for such practices to become customary and a stronger sense and knowledge or the care required is still years down I’d say when referrring to the small short-stay jails within the police stations.

    Reply
    1. Jeffrey Keller MD Post author

      Thanks, Adam! It is very interesting to those of us in the US to hear about how things are done elsewhere . . .

      Reply
  4. susan

    I work in two county jails that house less than 30 inmates. Opiate w/d we use Vistaril with tapered doses and Clonidine if the blood pressure is high, and Bentyl for stomach cramps.

    Reply

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