The management of opioid withdrawal

FRANÇAIS :
Actuellement, il existe peu de consensus sur la gestion du sevrage d'opiacés. Certains protocoles préconisent la réduction de la dose de méthadone ou l'administration d'agonistes alpha-adrénergiques (clonidine, lofexidine), et l'utilisation d'agonistes partiels comme la buprénorphine devient également courante. L'analyse de 213 publications montre que la gravité du sevrage est la même quand on donne des agonistes alpha-adrénergiques ou si on réduit la dose de méthadone, mais que les agonistes alpha2 entraînent des effets secondaires d'hypotension. La variété des traitements par les antagonistes permet d'éviter la standardisation. La buprénorphine apparaît comme un médicament prometteur ; elle diminue l'intensité du sevrage, a peu d'effets secondaires et un bon taux de rétention similaire à celui des alpha2-antagonistes. La rétention en traitement semble plus favorable en traitement résidentiel. La disposition psychologique avant et durant le sevrage peut tenir une place importante pour prédire la suite du traitement. Par contre, il n'est pas toujours possible de prévoir l'impact du protocole de sevrage sur le devenir à long terme.
ENGLISH :
To date there has been little consensus on best practice in the management of opioid withdrawal. Regimes involving reducing doses of methadone or the administration Of (x2-adrenergic agonists such as clonidine and lofexidine are most common, but the use of opioid antagonists to induce withdrawal, and the partial agonist, buprenorphine, are gaining in popularity. This paper reviews 213 published reports of interventions to manage opioid withdrawal. Rates of completion and severity of withdrawal are similar when managed with either x2-adrenergie agonists or reducing doses of methadone but a,-adrenergic agonists, particularly clonidine, are associated with a higher incidence of hypotensive side effects. Variability in the opioid antagonist treatment regimes prevents the identification of standard approaches. The use of opioid antagonists may increase completion rates, but with the risk of more severe withdrawal. Buprenorphine has considerable promise for the management of opioid withdrawal, being associated with lower withdrawal severity, fewer side effects and similar completion rates to withdrawal managed with x2-adrenergic agonists. Withdrawal in an in-patient setting is associated with higher completion rates than withdrawal in an outpatient setting. Psychological state prior to and during withdrawal may be important in determining withdrawal outcomes. It is currently not possible to determine to what extent the setting and detoxification protocol influences long-term outcomes. (Author's abstract.)