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Answer 2
  1. Provide detoxification with methadone. For a patient in opiate withdrawal, a basic issue to address is whether or not continued opiate prescribing is appropriate. The patient could have a chronic pain syndrome for which chronic administration of opioids is appropriate. However, this scenario does not apply to this case. A second issue to be addressed is whether referral for opiate agonist therapy (OAT) is more appropriate than is detoxification. Federal guidelines require a history of opiate addiction for at least 1 year and also at least 2 failed detoxification attempts in a 1-year period before referring for OAT. For those patients with heroin addiction who meet these and other federal criteria, OAT can be very effective. This patient has never had the opportunity of detoxification before, thus making OAT premature. Detoxification with methadone is the treatment of choice. Although clonidine can be a fairly effective medication for detoxification, when used alone it does not treat the full constellation of heroin withdrawal and is associated with orthostatic hypotension. Benzodiazepines do not treat the full syndrome of withdrawal when used alone. Naltrexone (an opioid antagonist with only marginal efficacy as an antirelapse agent for heroin dependence) would only worsen this patient’s withdrawal syndrome. Buprenorphine, a new medication for OAT, will soon be available as well.

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