Sean and I go back a long way. He first started treatment 15 years ago and has had quite a few treatment episodes over the period he has been with us. These tend to follow a pattern; he starts opioid substitution with methadone, titrates up to about 60mls at which point he stops using heroin. And then after a variable period of time - usually between 4-12 weeks he starts to use again - occasionally at first and then more regularly, often missing pick ups and appointments before dropping out of treatment for a spell. Sometimes he comes back to us after a few months, sometimes more than a year goes by, and there have been interruptions whilst he has been in prison.
He has often done quite well in prison, perhaps being away from his usual environment and has been released on a moderate dose of methadone a number of times, but then the usual pattern kicks in. At the beginning of this year he told me he was fed up with this recurring sequence of events but not sure how we could change this.
On discussing his previous treatment episodes, he told me that when he started methadone he quite quickly stopped having withdrawal symptoms - and this was the point at which his dose titration stopped. However he would still crave heroin and despite his best intentions his resolve would eventually crack and he would use heroin again; sometimes sporadically, but always increasing until the point of falling out of treatment.
On exploring this cycle with him, he felt there was constantly a trigger, like having extra money, bumping into the wrong people etc. Then it occurred to me that his craving might be the main factor. We discussed increasing his dose beyond merely stopping withdrawal and trying to see if we could stop his craving. I explained this didn’t mean he would never come off treatment and that long term abstinence could still be a goal, however to get to that point he first needed a sustained spell of not using heroin.
He agreed that we should try this and we titrated him over the next few weeks to 90mls of methadone. It is now 9 months on and he remains heroin free and is as well as I have ever seen him. I expect that at some point in the future he will want to try and reduce with a view to becoming abstinent. That will be at a time of his choosing, meanwhile he is enjoying not constantly fighting against craving.
Sean has made me wonder if we often under dose with OST in that we treat withdrawal symptoms yet leave our patients to deal with cravings? is simply controlling withdrawal enough? Whilst my experience with him is obviously purely observational it is gratifying to see this as an area picked up in the revised Drug Misuse and Dependence: UK Guidelines on Clinical Management (“the Orange Book”) and I now make a point of asking about craving as well as withdrawal symptoms, when assessing dose titrations.
Steve Brinksman is a GP in Birmingham and Medical Director at Swanswell. He is also SMMGP's Clinical Director.
This article first appeared as a Post It from Practice in DDN Magazine, November 2017.