A comparison of the withdrawal responses of heroin and methadone addicts during detoxification. M Gossop and J Strang BJP 1991, 158:697-699. Access the most recent version at DOI: 10.1192/bjp.158.5.697
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British Journal of Psychiatry (1991), 158, 697—699
A Comparison of the Withdrawal Responses of Heroin and Methadone Addicts during Detoxification MICHAEL GOSSOP and JOHN STRANG
This study compares the withdrawal responses of methadone and heroin addicts during a ten-day in-patient detoxification programme with methadone. Contrary to suggestions in the literature, the methadone group reportedmore severewithdrawalsymptoms duringboth the acute withdrawal phase and the recovery phase. There were no differences between the two groups in onset or duration of symptoms. Whereas there may be reasons to favour methadone as a maintenance drug, its use may lead to difficulties during withdrawal.
One of the most widely used methods of withdrawal for opiate addicts involves gradually reducing doses of oral methadone. It has been suggested that as many as 10 000 opiate addicts may be withdrawing on methadone at any one time in the US (Kleber et a!, 1980). Where users are dependent upon heroin, methadone is substituted for the heroin before withdrawal, and then reduced, usually over 10—21 days. This procedure has had considerable success when applied in an in-patient setting and previous studies have reported that more than 80°loof opiate addicts completed this sort of detoxification pro gramme (Gossop et a!, 1986; Gossop et a!, 1989a). Vogel eta! (1948) suggested that withdrawal from methadone was likely to be less severe but more prolonged than withdrawal from morphine. This view of methadone's withdrawal effects is widely accepted. For example, Jaffe (1985) states that the methadone withdrawal syndrome is “¿qualitatively similar to that of morphine, but it develops more slowly and is more prolonged, although usually less intense―; he also suggests that methadone with drawal symptoms are remarkably persistent and that as much as three weeks may elapse between the peak of withdrawal and the point at which symptoms begin to subside. Detailed investigation of the opiate withdrawal syndrome in response to methadone detoxification programmes has confirmed that residual withdrawal symptoms persist well beyond the last day of methadone administration (Gossop et a!, 1987, 1989b). However, it is interesting that many addicts believe that withdrawal from methadone is more severe than from heroin, and users commonly report that withdrawal from methadone is in some sense ‘¿worse'than that from heroin (Stewart, 1987). Robertson (1987) comments that the methadone withdrawal symptoms are “¿of a more severe nature than those associated with heroin―. Bone pains and muscular aches are prominent adverse effects attributed to methadone 697
by addicts, some of whom may even prefer an unmodified withdrawal from heroin to a short-term methadone detoxification (Hunt et a!, 1986). Heroin and methadone have both been used in the treatment and management of opiate addicts in the UK although, in practice, heroin has only been used in a very small number of cases. In recent years there has been a revival of interest in the possible uses of heroin. Ghodse et a! (1990) reported on the double-blind use of either heroin or methadone during the dose-assessment phase before the in patient detoxification of opiate addicts, and suggested that heroin addicts required more frequent doses of heroin during a stabilisation phase before detoxification. However, there have been no direct clinical comparisons of the relative severity or persistence of withdrawal symptoms when coming off heroin or methadone. The present study compares the responses of heroin and methadone addicts during a ten-day gradual methadone reduction schedule.
Method The subjects in this study were 83 consecutive admissions (60 men, 23 women, mean age 27.9 years) to an in-patient drug treatment unit and all were physically dependent on opiates, as confirmed by the presence of morphine metabolites
or methadone
in urine analysis, and by clinical
examination. Subjects were divided into a heroin and a methadone group according to their pre-admission type of opiate use. Forty-five subjects were categorised as being exclusively or primarily dependent on heroin (either illegally obtained, or prescribed) and 38 subjects as exclusively or primarily dependent on methadone. In 47 cases, subjects used only one type of opiate (heroin n = 37, methadone n = 10). It is common for addicts to use more than one type of opiate drug. In those cases where subjects used both heroin and methadone (n = 36), subjects were allocated to groups according to their major type of opiate dependence (defined by dose, and using the dosage conversion procedures
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GOSSOP AND STRANG
suggested by Banks & Wailer (1988)). Doses of methadone ranged from 10 mg to 105 mg (mode of 60 mg) per day. Total daily opiate doses before admission were calculated by converting methadone doses into heroin equivalents (as above). As there are many problems associated with any attempt to achieve an accurate formula for such conversions, some of which have been discussed by Johns & Gossop (1985), no attempt was made to express heroin and metha done doses in directly comparable and quantitative terms. However, it was felt important to obtain some index of dose. For this reason, the total daily opiate dose of the subjects (i.e. heroin
plus methadone
for those who used both drugs)
was calculated in terms of dose categories, and non parametric rather than parametric statistics were used in the analysis of data regarding dose categories. Subjects were divided into three dose categories: group 1, less than ½g (n = 35), group 2, ½—i ½g (n = 22), group 3, more than 1½g (n = 26). There was no difference between the methadone and heroin groups in pre-admission total opiate
dose levels (x@=0.49, P=0.82, NS). All subjects received a ten-day supervised in-patient methadone withdrawal. This involved daily reductions from
an individually tailored starting dose of methadone which had been established during the first three days after admission,
when
the patients
were given
a ‘¿trial'dose
of
methadone based mainly upon self-reported opiate use, and this dose was then titrated according to clinical observation
of their responses. In this study, two measures were taken of the subjects' opiate dose. The first was self-reported daily opiate use before admission; the second was the initial withdrawal dose of methadone prescribed at the start of
the ten-day detoxification procedure. This detoxification phase was the first stage of a more comprehensive
treatment
package and was not offered as a treatment in its own right: all subjects were encouraged to remain in hospital for a treatment package lasting for approximately 8—10 weeks. Withdrawal
responses were measured by means of the 12-
item Short Opiate Withdrawal Scale (SOWS). This self-rating scale was specifically devised for the measurement
of opiate
withdrawal symptoms. Both in its longer (32-item) version and in its present form, the total withdrawal score provides a reliable and valid measure of the opiate withdrawal syndrome (Bradley eta!, 1987; GOSSOP,1990). The 12 SOWS
items, each of which was rated on a four-point scale (0- nil, 1 —¿ mild, 2 —¿ moderate, 3 —¿ severe) were: (a) feeling sick! nausea, (b) stomach cramps, (c) muscle spasms, (d) feelings of coldness, (e) gooseflesh, (f) heart pounding, (g) muscular tension, (h) aches and pains, (i) weakness, (j) yawning, (k)runnyeyes,
and (1)problems sleeping/insomnia.
3
5
7
9
11
13
15
17
19
21
23
Days Fig. 1 Mean SOWS scores (methadone ( o ) and heroin ( •¿)
addicts) during withdrawal of methadone (days 1—10)and subsequently.
The means of the total SOWS scores for the two groups were compared during the acute withdrawal phase (days 1—13) and during the recovery phase (days 14—23).The methadone group showed significantly higher levels of withdrawal symptoms both between days 1 and 13 (t = 3.39, P
