Social therapy and medications were used to manage withdrawal symptoms. Social therapy entailed establishing a fixed and predictable structure, building relationships, gathering and clarifying information, motivational work, education and physical activity.
Standardised pharmacological treatment comprised clonidine and valproate in tablet form. Clonidine is a central alpha-2-adrenergic agonist which counteracts opioid withdrawal symptoms associated with noradrenergic hyperactivity (4). The agent offers relief for patients with dominant opioid withdrawal by reducing restlessness, muscle twitching and stress (4). Its efficacy is well documented in patients with mild to moderate symptoms (12). Clonidine may cause adverse effects, including hypotension and insomnia, especially in the first few days. A dosage of 50 – 150 μg three times daily was used until urine toxicology tests were negative for opioids, usually after 6 – 10 days.
Valproate is an antiepileptic that acts on brain GABA-A receptors. It has been used in our unit since 2002 to alleviate withdrawal symptoms and to prevent seizures and delirium tremens in patients with alcohol or benzodiazepine withdrawal. Its efficacy in preventing seizures and alleviating symptoms is similar to that of carbamazepine (13), but carbamazepine interacts with opioids (14) and has more adverse effects (15). Valproate should not be given to pregnant women (16). The dosage used was Orfiril long 600 mg twice daily. To quickly attain an adequate serum concentration, a loading dose of 1200 mg was given in oral solution. Orfiril was administered until benzodiazepines could no longer be detected in the urine.
Additional symptomatic treatment was determined on the basis of individual assessment: alimemazine was used for sleep disturbances; hydroxyzine for anxiety and agitation; paracetamol for somatic pain; ibuprofen for muscular pain; lactulose for constipation, metoclopramide for nausea, and loperamide for diarrhoea. Neuroleptics such as chlorprothixene and levomepromazine were used occasionally for sleep disturbances. Patients also received a daily dose of vitamins, and adequate fluids and nutrition.
The duration of treatment of withdrawal symptoms in this study was set to ten days. This was based on a previous study of polydrug users (8) and on detection times for the individual substances in the urine (17). Clinical experience has shown that the risk of severe withdrawal symptoms is related to drug detection time in the urine.
In this study, treatment was considered completed after ten days in the unit or upon a negative urine toxicology screen. An exception was made for cannabis, which can be detected in the urine for several weeks.
The Regional Ethics Committee (REC) considered the study to be a Quality Assurance Project exempt from the requirement of ethical approval. The study was approved by the Norwegian Centre for Research Data.