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Medical management of opioid dependence in South Africa. Medical practitioners in South Africa are increasingly confronted with requests to treat patients with opioid use disorders. Many do not possess the required knowledge and skills to deal with these patients effectively. This overview of the medical treatment of opioid dependence was compiled by an elected working group of doctors working in the field of substance dependence. Recommendations are based on current best practice derived from scientific evidence and consensus of the working group, but should never replace individual clinical judgement. Extent of the problem. Heroin is the main illicit opioid of abuse, with an increasing trend in South Africa. The use of heroin in combination with other drugs has also become popular. It includes 'nyaope' and 'pinch' mixture of cheap heroin and cannabis and 'sugars' mixture of low-quality heroin and cocaine, mixed with cannabis. This makes up a significant group of opioid abusers with concerning morbidity, in part because of the toxicity of other ingredients, including paracetamol. What is opioid dependence? Opioid dependence is a chronic relapsing disease that develops from repeated self-administration of opioids, including heroin, over-the-counter and prescription opioids. Genetic and environmental factors contribute to the development of this disease. Routine drug screens test positive only for opiates and special testing is required for synthetic opioids. Opioid dependence is associated with substantial morbidity and mortality. It is, however, encouraging that the proportion of clients who sustain abstinence increases with time, and the addicted proportion declines. Opioid abuse and dependence require different interventions. Abuse implies that someone persistently or sporadically uses substances in a manner that causes negative consequences. The Diagnostic and Statistical Manual of Mental Disorders, 4th revision DSM-IV , defines it as a maladaptive pattern of substance use that leads to impairment or distress manifesting by any of the following: failing to fulfil important obligations at work, school or home; using substances in a manner that is physically hazardous; or having legal, social or interpersonal problems due to or exacerbated by the substance. Abuse is generally managed by using a psycho-educational approach, e. Medical model for the treatment of opioid dependence. The aim of treatment for opioid dependence is total abstinence from all opioids. In clinical practice, the short-term success rate for total abstinence is low, even following inpatient treatment. Total abstinence does, however, remain an achievable goal for some patients. Abstinence was significantly associated with programme completion and aftercare attendance. This may involve the use of long-term oral substitute opioids until the addict is ready to change behaviour and maintain sobriety. The two opioids used for this substitution therapy are methadone and buprenorphine. The medical management of opioid dependence can thus be conceptualised as involving two potential options:. Rapid detoxification from all opioids and relapse prevention. Assisting opioid-dependent individuals to achieve the goal of abstinence from all opioids rapidly involves:. Identification and motivation. The problems of opioid-dependent individuals evoke shame, denial and defensiveness in the addict, and negative responses in health care workers. Social workers, educators, workers in the legal and judicial system, health care workers, and other persons involved with these individuals should be educated to recognise opioid use disorders early. Health care workers need to learn skills in dealing with resistance and motivating opioid abusers to engage in treatment services e. Management of co-morbid medical and mental health problems. Heroin dependence is associated with a high incidence of co-morbid medical and mental health complications, which require separate identification and treatment. Fatal overdose is tragic and heroin is the drug most implicated in fatal accidental poisonings in addicts. Medical complications may arise from non-sterile injecting practices or needle sharing, and include skin or systemic infections, HIV or hepatitis B or C transmission, and complications because of adulterants, which may include talcum pneumonitis and renal complications. Common psychiatric problems include depression, protracted anhedonia even with long-term abstinence and personality disorders. Psychosis is rare but may arise from poly-substance abuse. Detoxification, the first step of treatment, allows the addict to engage in the most important step of treatment, namely relapse prevention. It involves a graded and controlled reduction in tolerance to opioids, minimising unpleasant withdrawal symptoms. Two medication groups are used, often in conjunction: opioid substitution and symptomatic medication. Substitution detoxification involves the use of either a full or partial opioid agonist, which is prescribed at an individualised dose that alleviates withdrawal symptoms without causing intoxication. It is then gradually reduced, usually over a period of 1 - 3 weeks, allowing the level of tolerance to normalise in a manner that is tolerable for the addict. It is important to ensure that patients are in withdrawal objective rating scales may be useful, e. Clincal Opioid Withdrawal Scale COWS before administering substitution opioids in order to prevent accidental overdose full agonists or precipitate withdrawal partial agonists. Symptomatic medications alleviate some of the withdrawal symptoms and are used for mild withdrawal or to reduce the requirement for substitution opioids. Substitution detoxification options available in South Africa:. Non-substitution detoxification. Outpatient detoxification should be considered only in selected cases where it is considered safe to do so risk of overdose and death. An infrastructure for daily supervised consumption of substitution opioids, regular follow-up and monitoring via random drug testing is required. Methadone should be used with great caution in outpatients, because of the risk of accidental overdoses; buprenorphine may be a safer option. Inpatient detoxification is safer, especially with high levels of opioid tolerance, poly-drug use, other co-morbidities and in pregnancy. Long-term supervised care is important during pregnancy and substitute prescribing may be appropriate. Patients should be educated that their level of tolerance is reduced during detoxification. The dose of illicit opioid that was used prior to detoxification may subsequently cause overdose. A programme, including psychosocial rehabilitation and pharmacological interventions, to prevent relapse back to opioids must be in place prior to embarking on detoxification. Psychosocial interventions provide individuals in recovery with the skills to maintain sobriety and include cognitive behavioural therapy, motivational enhancement therapy, spiritual step programmes and addressing social needs, such as homelessness, unemployment and family reintegration. Limited pharmacological interventions are available. Naltrexone is an opioid antagonist blocking opioid receptors without producing an effect, making it difficult to get high. It has been used orally, as a depot monthly injection or as a longer-term implant formulation. Naltrexone is unfortunately no longer registered in South Africa, but can be prescribed with Medicines Control Council MCC approval per patient and then ordered from overseas, e. Only doctors experienced in treating opioid disorders should prescribe naltrexone. Opioid dependence is a chronic disorder and relapse is common. Relapse could be viewed as a learning and growth opportunity. Many clients find that engaging in an aftercare programme, for example a self-help support group like Narcotics Anonymous, provide them with a useful support structure and may reduce relapse. Substitute opioid prescribing. Some addicts are unable to give up their opioids, and interventions to reduce harm may be considered until they are able to achieve total abstinence. Given the chronic relapsing nature of opioid dependence and frequent poor results of rapid detoxification and relapse prevention, treatment to reduce drug-related harm has become an important intervention in many countries. Substitution prescription of opioids, though not widely used in South Africa, is well established internationally and is supported by a large body of research literature and clinical practice. Substitution is suitable for addicts who want to stop illicit opioid use, but are unable to achieve abstinence from all opioids at that time. They receive a prescribed individualised dose of methadone or buprenorphine at suitable doses to suppress withdrawal and craving, and in the case of buprenorphine, to block the 'high' if illicit opioids are used on top. This provides the opportunity to stabilise their lifestyle, develop insight and reduce harm from illicit drug use. Methadone maintenance treatment has been shown to reduce morbidity, 15 including HIV risk, 16 incarceration, 17 other substance use 18 and mortality 19 associated with heroin dependence, and improves treatment retention. Compared with detoxification and psychosocial interventions, methadone maintenance treatment has a better outcome 20 and the same is true for buprenorphine. This alcohol-containing cough syrup has a high sugar content and high viscosity, making accurate dispensing difficult. Users have to consume large volumes of the diluted formulation syrup v. Methadone is not currently registered for the management of opioid dependence in South Africa off-label use. Methadone has good oral bioavailability and its long half-life allows for daily oral dosing. Because of its full agonist action, methadone substitution could be associated with a risk of accidental overdose. Buprenorphine is available as a sublingual 2 mg or 8 mg tablet and its long half-life allows for once-daily or alternate-day supervised consumption. Because it is a partial agonist, with increasing dose the active effects plateau, making it safer and less likely to result in accidental overdose than full agonists. Individuals also report a 'clearer head' with buprenorphine, in contrast to the 'mental clouding' sometimes experienced with methadone. The choice of substitution drug rests with the prescribing physician. A higher level of tolerance, patient preference and contraindications to use buprenorphine may be indications for choosing methadone. Patients should be carefully selected for substitution treatment. They must have a diagnosis of opioid dependence with evidence of physical dependence tolerance, withdrawal. Ideally they should have had at least one failed attempt at standard detoxification and rehabilitation, be well motivated and give informed consent. Concomitant medical or psychiatric problems increase the complexity of management and may increase the risk of overdose and death. Other precautions include high-risk poly-drug use, especially drugs that cause sedation such as alcohol or benzodiazepines, and individuals who are at risk of self-harm. Substitution prescription poses risks if unregulated, including the potential for unsafe or unethical practices by medical professionals, black-market diversion and 'doctor hopping'. It is therefore important that accreditation, guidelines and proper legislation be put into place to ensure that doctors who do substitution prescribing are properly trained and regulated to ensure patient safety. Only medical practitioners who have received training or have experience in substitution prescribing should provide this treatment. Important elements include regular monitoring of patients, random drug screening to pick up relapse to illicit opioids or other addictive substances, and ongoing psychosocial interventions. Diversion of medication to the black market remains a valid concern, and adequate supervision of patients with regard to opioid dispensing and consumption is essential. A patient register would help to prevent 'doctor-hopping'. The ultimate aim of opioid substitution treatment is eventual dose reduction and abstinence when the individual is ready, and treatment goals should be reviewed every 3 - 6 months. Some argue that a small number of addicts require lifelong substitution therapy owing to a relative endogenous opioid deficiency. Better results are obtained when opioid substitution is continued for at least 1 year before attempts are made to reduce the dose. Schering Plough sponsored the meetings of the working group and publication. The authors served as members of the Schering-Plough advisory board. Leshner AI. Addiction is a brain disease, and it matters. Science ; Heroin dependence in an English town: year follow-up. Br J Psych , Brief interventions for alcohol problems: a review. Addiction ; Motivational Interviewing, Preparing People for Change. New York: Guilford Press, Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses. In-patient treatment of opiate dependence: medium-term follow-up outcomes. Br J Psych ; Remission from drug abuse over a year period: Patterns of remission and treatment use. Am J Public Health ; Methadone at tapered doses for the management of opioid withdrawal. Buprenorphine for the management of opioid withdrawal. Alphaadrenergic agonists for the management of opioids withdrawal. Management of opiate dependence. Curr Opin Psych ; 16 3 : Methadone maintenance therapy versus no opioids replacement therapy for opioid dependence. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Gunne LM, Gronbladh L. The Swedish methadone maintenance program: a controlled study. Drug Alcohol Depend ; 7 3 : Reducing the risk of AIDS through methadone maintenance treatment. J Health Soc Behav ; 30 6 : Dole VP, Joseph H. Long-term outcome of patients treated with methadone maintenance. Ann NY Acad Sci ; Do methadone patients substitute other drugs for heroin? Predicting substance use at 1-year follow-up. Am J Drug Alcohol Abuse ; 19 4 Retention in methadone maintenance and heroin addicts' risk of death. Addiction ; 89 2 : Methadone maintenance vs. JAMA ; Lancet ; Correspondence: L Weich lizew sun. All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License. Services on Demand Article. English pdf Article in xml format Article references How to cite this article Automatic translation. Access statistics. Cited by Google Similars in Google. Extent of the problem Heroin is the main illicit opioid of abuse, with an increasing trend in South Africa. Medical model for the treatment of opioid dependence The aim of treatment for opioid dependence is total abstinence from all opioids. The medical management of opioid dependence can thus be conceptualised as involving two potential options: Achieving total abstinence rapidly using standard rapid detoxification procedures withdrawal over 7 - 21 days , followed by relapse prevention strategies. Transferring the addict from abused opioids onto an individualised dose of substitution opioid thus markedly reducing or preventing illicit drug use, allowing patients to stabilise their lifestyle , and slowly detoxifying them when they are ready. This shift towards harm reduction is not widely accepted in South Africa as there is limited infrastructure and no legislation to accommodate opioid substitution therapy. It is important that South Africa develops the capacity to provide substitution prescription in a safe and controlled manner. Rapid detoxification from all opioids and relapse prevention Assisting opioid-dependent individuals to achieve the goal of abstinence from all opioids rapidly involves: Identification and motivation Detoxification Management of co-morbid medical and mental health problems Relapse prevention. Identification and motivation The problems of opioid-dependent individuals evoke shame, denial and defensiveness in the addict, and negative responses in health care workers. Management of co-morbid medical and mental health problems Heroin dependence is associated with a high incidence of co-morbid medical and mental health complications, which require separate identification and treatment. Detoxification Detoxification, the first step of treatment, allows the addict to engage in the most important step of treatment, namely relapse prevention. Partial agonist: Buprenorphine. Use benzodiazepines with great care because of the risk of overdose with opioids and partial opioid agonists and the risk of co-morbid abuse and dependence. Relapse prevention A programme, including psychosocial rehabilitation and pharmacological interventions, to prevent relapse back to opioids must be in place prior to embarking on detoxification. Substitute opioid prescribing Some addicts are unable to give up their opioids, and interventions to reduce harm may be considered until they are able to achieve total abstinence. References 1. How to cite this article.

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Buying Heroin Stellenbosch

As the access to this document is restricted, you may want to search for a different version of it. Dunkle, Kristin L. Stimson, G. Needle, R. Full references including those not matched with items on IDEAS Most related items These are the items that most often cite the same works as this one and are cited by the same works as this one. Pronyk, Paul M. Morojele, Neo K. Bhana, Deevia, Watt, Melissa H. Mendelsohn, Joshua B. Rohini Somanathan, You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:eee:socmed:vyip See general information about how to correct material in RePEc. If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about. If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form. If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the 'citations' tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation. For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Catherine Liu email available below. Please note that corrections may take a couple of weeks to filter through the various RePEc services. Economic literature: papers , articles , software , chapters , books. My bibliography Save this article. Dewing, Sarah. In , a rapid ethnographic assessment was conducted in Durban, South Africa, to learn more about patterns of drug use and HIV risk behaviors among drug-using, street-based sex workers. Field teams recruited 52 current injection and non-injection drug users for key informant interviews and focus groups, and they conducted mapping and observation in identified high-risk neighborhoods. Key informants were offered free, voluntary counseling and HIV rapid testing. The results of the assessment indicate that in this population, drugs play an organizing role in patterns of daily activities, with sex work closely linked to the buying, selling, and using of drugs. Participants reported using multiple drugs including crack cocaine, heroin, Ecstasy and Mandrax, and their choices were based on their expectations about the functional role and behavioral and pharmacological properties of the drugs. The organization of sex work and patterns of drug use differ by gender, with males exercising more control over daily routines and drug and sexual transactions than females. Activities of female sex workers are subject to considerable control by individual pimps, many of whom also function as landlords and drug dealers. A strong hold over the overlapping economies of drugs and sex work by a few individuals extends to control of the physical and social settings in which sex is exchanged and drugs are sold and used as well as the terms under which sex work is carried out. The potential for accelerated HIV spread is considerable given the evidence of overlapping drug-using and sexual risk behaviors and the mixing patterns across drug and sexual risk networks. Handle: RePEc:eee:socmed:vyip as. Most related items These are the items that most often cite the same works as this one and are cited by the same works as this one. Corrections All material on this site has been provided by the respective publishers and authors. Help us Corrections Found an error or omission? RePEc uses bibliographic data supplied by the respective publishers.

Buying Heroin Stellenbosch