I am a psychiatrist in the Southeast and am being asked to see persons from Louisiana and Mississippi displaced by Hurricane Katrina. Some of these persons have a history of substance abuse. What is a good protocol for outpatient opiate detoxification?

Psychiatrist, Atlanta

Opiate detoxification in the outpatient setting often depends on what services are available in the community. Many clinicians think that a methadone maintenance or taper regimen, combined with substance abuse treatment therapy, offers the best chance to prevent relapse. If possible, enrolling a patient promptly in such a program should be considered. Regardless of detoxification method, referral for psychosocial drug treatment is indicated.

Most municipalities have specific laws about the use of methadone for detoxification, only allowing licensed clinics to dispense the medication. Prescribing methadone for outpatients outside a defined program is generally not recommended.

Detoxification can be achieved without the use of opiates by ameliorating the flu-like symptoms of the withdrawal period. Recommend plenty of rest, food, and fluids during the coming days. A common cause of discomfort during withdrawal is sympathetic nervous system hyperactivity; this is best suppressed by clonidine, 0.1 mg twice daily for 3 days. Obtain an initial blood pressure measurement before starting treatment with clonidine, and do not use this medication in patients who have a history of hypotension. Advise patients receiving this regimen to avoid rising quickly from chairs or bed.

Ibuprofen, 400 to 800 mg 3 times daily, will decrease the aches and pain of withdrawal, and diphenhydramine, 25 mg every 6 hours, is effective for the sinus congestion that often occurs. Because GI symptoms are common, you may wish to add dicyclomine for cramping, loperamide for diarrhea, and promethazine for nausea.

Some clinicians use benzodiazepines during withdrawal to help reduce anxiety and agitation; however, given that the patient is already struggling with drug abuse, caution should be used when providing controlled substances. If you choose to order a benzodiazepine, use a low dose of a longer-acting agent, such as clonazepam, 0.5 to 1 mg twice daily, and only prescribe a few days' supply.

Remember that intravenous opioid abusers are at high risk for HIV infection and hepatitis. If possible, order laboratory screening tests and be sure to strongly counsel your patient about these risks.

Scott Zeller, MD

Chief, Psychiatric Emergency Services

Alameda County Medical Center

Oakland, Calif