Darwin TELIAS, MD
Joram NIR-HOD. D.C.
Telias, D., Nir-Hod, J. (2000) Buprenorphine-ketorolac vs. clonidine-naproxen in the
withdrawal from opioids. International Journal of Psychosocial Rehabilitation. 5, 29-33.
The authors analyzed the comparative results of two groups of patients undergoing detoxification from opiates: one group received a Clonidine-Naproxen protocol, and the other received Buprenorphine-Ketorolac. Success rate of Clonidine-Naproxen (CN) was 81%. and success rate of Buprenorphine-Ketorolac (B-K) was 73%, success defined as patients who finished detoxification procedures and were drug-free at the end.
Despite the better results for the CN group, BK was much better accepted by patients. One of the advantages of the Buprenorphine protocol was that it did not require close supervision and monitoring, thus abating the costs significantly.Buprenorphine doses used were lower than average reported in literature, and the authors attribute this to the concomitant use of Ketorolac.
The authors recommend the use of BK in order to increase the number of patients asking for treatment. The addictive potential of Buprenorphine is emphasized but also the misuse of Clonidine by patients attempting at self detoxification is brought to attention.
The need for an effective and accepted method of opioid withdrawal is ever increasing. Different methods have been tried, but none has proven to be perfect (1), (2). One of the principal problems of most methods is that they require hospitalization, and are consequently expensive. Other, less expensive methods are not easily accepted by patients asking for withdrawal, either because they are painful or because the side effects are undesirable.
Classical maintenance-detoxification methods, such as methadone detoxification, are not accepted by both public and some institutions, due to the preconcepts about methadone, although methadone detoxification seems to be the most effective and less troublesome method for ambulatory detoxification (3).
A new concept on opiate detoxification with Clonidine has been developed in Israel, called "house detoxification" (4). In this method, the patient receives instructions about the use of Clonidine, and performs the detoxification at home, under family surveillance.
Two varieties of this procedure are used: in the first, the family receives specific instructions about the use of a digital sphygmomanometer and about Clonidine doses the patient has to receive, and about blood pressure monitoring which permits or does not permit to administer the Clonidine. At the end of the procedure (usually from 7 to 10 days) the patient returns to the clinic for final check-up and directions for continuation of psychosocial treatment.
In the second variety, a team composed of a doctor and/or nurse, social worker and counselor visit the patient at home, check blood pressure and advise about continuation of medication, while at the same time starting the psychosocial intervention, which is later continued.
We developed a different protocol for ambulatory detoxification, using a combination of Buprenorphine and Ketorolac, to be used as the first variety described above, and which was well accepted by patients.
MATERIAL AND METHODS
In an attempt to establish the comparative efficacy of two relatively inexpensive ambulatory methods, we studied the results of 32 patients who were given a Clonidine-Naproxen protocol according to the first variety described, and 81 who were given a Buprenorphine-Ketorolac protocol, also on an ambulatory basis. Patients on B-K did not have to be monitored, and consequently the cost of the treatment was considerably lower. The treatments were carried out at a private clinic in Tel Aviv.
Initial daily doses of Buprenorphine were in average lower than generally recommended, (5), (6), (7), and, in our opinion, this was possible due to the use of Ketorolac.
The use of Ketorolac together with Buprenorphine was suggested by the paper by CANADEL.-CARAFI. J. et al. (8). and it was based upon the rationale that providing the patient with two different analgesics: an opioid one (Buprenorphine). and a non-opioid one (Ketorolac) would greatly improve the degree of analgesia, thus making the treatment more symptom-free.
Data for the two groups was as follows:
GROUP 1 (BUPRENORPHINE-KETOROLAC, BK)* - Success defined as percentage of patients who finished treatment and were detoxified at the end. GROUP 2 (CLONIDINE-NAPROXEN, CN) N = 82
Average age: 32 (range: 22-47)
Reported average daily use of Heroin: 0.84 grams
Average length of treatment: 9.75 days
Average initial dosage of Buprenorphine: 1.80 mgs/day
Succeeded: 60 (73%) (*)
N = 32
Average age: 32 (range: 24-49)
Reported average daily use of Heroin: 1.18 grams.
Average length of treatment: 9.5 days
Average initial dosage of Clonidine: 900 micgr/day
Succeeded : 26 (81%) (*)
Buprenorphine - Ketorolac clonidine - naproxen Number 82 32 Average age 32 (22-47) 32 (24-49) Daily use of Heroin 0.84 grams 1.18 grams Average length of treatment 9.75 days 9.5 days Average initial medication dose 1.80 mgs./day 900 micgr/day Succeeded (% of patients who finished treatment successfully) N = 60 (73%) N = 26 (81%)
From the above it seems clear that success rate of Clonidine-Naproxen (CN) is higher than that of Buprenorphine-Ketorolac (BK).
Nevertheless, there are other considerations to the problem:
First of all, we should consider the problem of logistics. The use of Clonidine requires frequent blood-pressure check-ups, which are not easily carried out at home. There is usually a need to either send a nurse home to check blood pressure, or to provide the patients and/or their families with a digital sphygmomanometer for self use. Not every patient can afford a digital sphygmomanometer. Sphygmomanometers, when given to take home, have a tendency to disappear or malfunction. With this method, families are required to cooperate in a degree higher than generally accepted by them, and not all families are ready to provide such a degree of cooperation. Consequently not all patients may use this method.
In second place, we have to consider that CN has good, but not excellent results in preventing the symptoms of withdrawal (9, 10), and patients more often than not complain of pain and other symptoms of the withdrawal syndrome, not entirely suppressed by either Clonidine or Naproxen. Many patients refuse to start this method, because they have heard, or know from previous experience, that symptoms are not totally avoided.
In third place there is the fact that in the first few days of CN patients are usually unable to function properly, they have to lose working days and give explanations as to why they were absent. In the cases when the patient was working despite the addiction, this is undesirable.
Using BK allowed the patients to function normally since the first day of treatment, thus avoiding social and labor problems.
This condition apparently enticed many addicts to come for treatment who had never dared to do so before.
Although the Clonidine-Naproxen protocol was more effective than the Buprenorphine-Ketorolac one, the authors are of the idea that the Buprenorphine-Ketorolac protocol is more attractive for the patients, and entices them to come for treatment more often and more willingly than the Clonidine-Naproxen protocol.
In places where the problem is to make treatment attractive, so as to reach more potential patients and bring them forward, the use of the Buprenorphine-Ketorolac protocol is advisable.
Nevertheless, it must always be taken into consideration that Buprenorphine poses a risk for addiction, although lower than Morphine (11), (12), and the use of Buprenorphine has to follow all the restrictions concerning the use of any other addictive substance.
Clonidine, on the other hand, is not considered addictive in itself. The authors could not find literature concerning the illegal or irrestricted use of clonidine.
Despite the lack of literature on the subject, though, many patients report having used Clonidine freely and without medical supervision, in attempts at self-medicated withdrawal from opioids.
The irrestricted use of Clonidine seems to have been connected with some deaths among the drug-addicted population in Israel, and consequently also Clonidine use should be closely supervised and restricted.
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