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Heroin withdrawal management needs multidisciplinary approach 

14 Jun 2021

  • Pharmacological therapy, psychosocial support, continuous monitoring, follow up recommended 

By Ruwan Laknath Jayakody    Owing to the widespread and increasing use of heroin in Sri Lanka, medical professionals should keep in mind the possibility of heroin users developing seizures due to withdrawal, even though seizures are a less common manifestation of heroin withdrawal, a local medical case report noted.   The case report revolved around a patient with heroin withdrawal presenting with newly onset seizures, which is said to be the first such case reported in Sri Lanka. It was authored by B.M.D.B. Basnayake, T. Kannangara, W.M.A.S.R. Wickramasinghe and S.N. Wijesena (all attached to the Kandy National Teaching Hospital’s Department of Medicine) and was recently published in the Anuradhapura Medical Journal.  Heroin (Diacetylmorphine) is an opioid drug derived from the seed pod of the poppy plant (Papaver somniferum). It is highly addictive. The abuse of this drug as pointed out by A.G. Schauss in the Attenuation of the Heroin Withdrawal Syndrome by the Administration of High Dose Vitamin C, depends on many factors including genetic and psychosocial factors. It is, Basnayake et al., emphasised, a chronic and relapsing disorder with patients exhibiting compulsive drug seeking and drug taking behaviour. Heroin addiction is both a health and social problem, associated as Basnayake et al. mention, with significant morbidity and mortality.   J.M. Cami and M. Farre explain in Drug Addiction that the chronic usage of heroin will cause changes in the central nervous system which lead to tolerance, physical dependence, sensitisation, craving, and relapse. If the patient reduces or ceases heavy and prolonged heroin use, it will cause, according to the April 2014 National Guidelines for the Medication Assisted Treatment of Opioid Dependence, the substance specific syndrome. The clinical features of the heroin withdrawal syndrome include as mentioned by Basnayake et al., muscle cramps, arthralgia (painful joint stiffness and swelling), anxiety, nausea, vomiting, diarrhoea, malaise, mydriasis (dilation of the pupil), piloerection (the reflex of producing goose bumps or the erection or bristling of the hair of the skin), diaphoresis (excessive and abnormal sweating), rhinorrhea (runny nose), lacrimation (the secretion of tears), insomnia and less commonly, confusion, convulsions, collapse and coma. As Basnayake et al., explain, the half life of the opioid that is causing the withdrawal syndrome is what determines both the onset and duration of the symptoms. During heroin withdrawal, the symptoms according to N.S. Miller and M.S. Gold's the Management of withdrawal syndromes and relapse prevention in drug and alcohol dependence and K. Rasmussen, D.B. Beitner-Johnson, J.H. Krystal, G.K. Aghajanian and E.J. Nestler’s Opiate withdrawal and the rat locus coeruleus (a small nucleus located in a part of the brainstem which is the main source of noradrenaline {a hormone that functions as a neurotransmitter} in the forebrain): behavioural, electro-physiological, and biochemical correlates, peak in 36 to 72 hours and may last for seven to 10 days.   Structural changes in neurons can occur due prolonged exposure to heroin which may in turn also contribute to withdrawal symptoms such as seizures as noted by Cami and Farre, Rasmussen et al., L. He, J. Fong, M.V. Zastrow and J.L. Whistler in the Regulation of opioid receptor trafficking and morphine tolerance by receptor oligomerisation (a chemical process) and L. Sklair-Tavron, W.X. Shi, S.B. Lane, H.W. Harris, B.S. Bunney and Nestler’s Chronic morphine induces visible changes in the morphology of mesolimbic (a pathway in the brain) dopamine neurons.  While there are many causative factors for seizures, in adults, it can be mainly due to, among others such as metabolic disorders, trauma, brain tumours and other space occupying lesions, and infectious diseases, both illicit drug abuse and withdrawal from alcohol and drugs, as noted in the Current Diagnosis and Treatment by McGraw-Hill Medical and Seizures and Epilepsy by Harrison’s Principles of Internal Medicine, and is therefore, often seen in substance abusers. These seizures, J.C.M. Brust’s Seizures and substance abuse: treatment considerations explains, may be due to direct causes such as intoxication or withdrawal or owing to indirect causes such as central nervous system infections, a stroke, cerebral trauma and metabolic derangement. Seizures due to heroin withdrawal are however, Basnayake et al., point out, less common than in the case of withdrawal from sedatives like barbiturates.  That said, E.F. Wijdicks and F.W. Sharbrough notes in New onset seizures in critically ill patients that in the case of critically ill patients who have been treated with sedatives and narcotics, the sudden withdrawal of narcotic drugs may be a significant causative factor for newly onset seizures.  Basnayake et al., reported a patient experiencing heroin withdrawal who presented with newly onset recurrent attacks of seizure episodes.    Case report  A 38-year-old previously healthy male had presented with four episodes of generalised (involving the entire body) tonic (a slow and likely graded physiological response characterised by the stiffening of muscles) clonic (a set of involuntary and rhythmic muscular contractions and relaxations, characterised by rhythmical jerking and twitching) seizures within the course of two days. These episodes were associated with frothing, tongue bites (marks were seen on the tongue) and post-ictal (the altered state of consciousness after a seizure) drowsiness. In between the seizure attacks, the man had regained consciousness. He did not report a history of fever, head trauma or recent alcohol or other drug abuse. He was a heroin addict, using the substance for 15 years on a daily basis, and had withdrawn for four days as he was undergoing a rehabilitation programme.  Following other examinations and investigations, Basnayake et al., noted that the findings were suggestive of diffuse cortical dysfunction (caused by disorders that affect large and specific areas of the brain if they cause the swelling of or put pressure on a large area of the brain) consistent with an encephalopathic (a disease or disorder or damage or malfunction or dysfunction or degeneration that affects or alters the function or structure of the brain with its hallmark being an altered mental status) state.   Taking into account all these aspects, it was concluded that the aetiology of the seizure was directed towards withdrawal from heroin.  Although he was started on sodium valproate (used to treat epilepsy and bipolar disorder, and prevent migraine headaches and seizures) for the purpose of controlling the seizures, it was stopped after four days (not long term) as per the neurological opinion. He was subsequently discharged without drugs and advised to continue the rehabilitation programme. During the over one year follow up at the medical clinic, no further fits or adverse neurologic sequelae (a condition which is the consequence of a previous disease) were encountered.  The main objectives of patient care in heroin withdrawal are to relieve distress, avoid severe withdrawal manifestations, maintain proper compliance in ongoing treatment, disturb the pattern of heavy and regular drug use, and assist in resolving other associated problems, Basnayake et al., elaborated, noting that in this regard, non-pharmacological therapies primarily focus on patient assessment, treatment matching and psychosocial support while in terms of the pharmacological therapies, one of the basic principles in managing drug withdrawal is to use an agent from the same pharmacologic class or one that has a degree of cross tolerance. Basnayake et al., further noted that the drugs used in such pharmacological management are analgesics in the opioid category, synthetic opioids, synthetic opioid agonists (a chemical that binds to a receptor and activates the receptor to produce a biological response) and opioids. According to the aforementioned National Guidelines, Miller and Gold, and Buprenorphine (opioid) in opiate withdrawal: a comparison with clonidine (used among others to treat drug withdrawal) by A.K. Nigam, R. Ray and B.M. Tripathi, due to the poor efficacy and side effects, some such drugs have been taken out from the management of the condition. Brust notes that in the case of patients with seizures where the aetiology is suspected or diagnosed to be solely drug withdrawal, long term preventive care using anticonvulsants is usually not indicated.  In conclusion, Basnayake et al., emphasised that the management of the heroin withdrawal syndrome requires a multidisciplinary approach including the provision of pharmacological therapy and psychosocial support, and continuous monitoring and follow up.


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