COMMUNITY PRESCRIBING FOR OPIATE DEPENDENCY

A major overall objective in the on-going management of the illicit substance misuser is to promote stabilisation of lifestyle. Illicit dependent substance misuse leads to a daily pattern of behaviour revolving around obtaining money for drugs, purchasing drugs and using drugs. Such a lifestyle precludes any involvement in more productive and socially responsible activity, and traps the user in a cycle of behaviour that may seem impossible to break. The more damaging substances are also those with relatively short durations of action (heroin and cocaine/ crack cocaine), this short duration of action leading to a more frequent repetition of the behaviour.

The prescription of opiate substitute medication may offer a means of escape from this cycle by both removing the need to engage in acquisitive crime and reducing contact with the illicit drug using community. Additionally, prescription of a relatively long-acting substitute such as methadone, reduces the frequency of substance use and reduces the intensity of peaks and troughs (intoxication and withdrawal) regularly experienced by the illicit heroin user. The overall effect should be to provide biological stability, thus providing a

foundation for implementing changes in the user's social and personal situation which will be necessary to achieve long-term change.

Commencement of prescribing should only take place after a referral to and assessment by specialist services. Opiate drug withdrawal is not life-threatening and requests for immediate prescribing of methadone should always be resisted. There is a theoretical risk of cardiovascular complications supervening in the elderly patient with pre-existing cardiac disease, and a potential risk of premature labour or spontaneous abortion being precipitated in the pregnant addict in withdrawal.An acute referral to the appropriate medical/obstetric team may sometimes be indicated in such cases.

There are two licenced alternatives for opiate substitution - methadone and Subutex (a formulation of buprenorphine). There are various advantages and disadvantages associated with both drugs, knowledge of which should lead to the appropriate choice being made for an individual patient.

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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.