HOW TO TREAT OPIOID DEPENDENCE 2025

HOW TO TREAT OPIOID DEPENDENCE 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 8

OPIOID DEPENDENCE

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 8

OPIOID DEPENDENCE

I. DEFINITION  

Opioids refer to a broad class of substances, including natural compounds (e.g., opium resin), semi-synthetic derivatives, and synthetic analogs (e.g., morphine, heroin, methadone). Opioid dependence involves both physical and psychological reliance, with psychological dependence serving as the biological basis for relapse.

II. ETIOLOGY  

1. Psychological Factors  

– Curiosity and desire for novel sensations, particularly among adolescents.  

– Tendency to imitate adult behaviors (e.g., alcohol, tobacco, drug use) as a means of asserting maturity.  

– Reactions to family or social discord, with opioid use perceived as an escape from life stressors.  

2. Social and Family Factors  

– Lack of family oversight, education, or clear disapproval of substance use, sometimes coupled with concealment of a relative’s drug use. Overindulgent parenting or frequent family conflicts may also contribute.  

– Lax management in schools and inadequate governmental measures to dismantle drug injection networks.  

3. Biological Factors  

– Opioid dependence often co-occurs with psychiatric disorders such as depression, anxiety, schizophrenia, or antisocial personality disorder.

III. DIAGNOSIS  

1. Opioid Dependence Syndrome  

Per the International Classification of Diseases, 10th Revision (ICD-10, 1992), opioid dependence is diagnosed when three or more of the following occur together for at least one month or, if less than one month, recur together over 12 months:  

– Intense craving or compulsion to use opioids;  

– Difficulty controlling opioid use (timing, quantity, or method);  

– Characteristic withdrawal syndrome upon cessation or reduction of opioid use;  

– Evidence of tolerance (e.g., increasing doses needed to achieve effects);  

– Neglect of previous interests or pleasures to prioritize obtaining, using, or recovering from opioids;  

– Continued use despite clear evidence of harmful consequences.  

2. Opioid Withdrawal Syndrome  

Per ICD-10, opioid withdrawal includes at least three of the following:  

– Craving for opioids;  

– Nasal congestion or sneezing;  

– Lacrimation;  

– Muscle pain or cramps;  

– Abdominal cramps;  

– Nausea or vomiting;  

– Diarrhea;  

– Pupillary dilation;  

– Goosebumps or chills;  

– Tachycardia or hypertension;  

– Yawning;  

– Restless sleep.  

3. Ancillary Testing  

– Urine Testing: Dipstick tests (4- or 6-panel: morphine, amphetamines, MDMA, THC) or chromatography for opioids and other drugs.  

– Hematology: Complete blood count (pre/post-treatment, daily if abnormal).  

– Urinalysis.  

– Biochemistry: Glucose, urea, creatinine, uric acid, lipids (cholesterol, triglycerides, LDL, HDL); CK, GOT, GPT, GGT, electrolytes (pre/post-treatment).  

– Microbiology: HIV, HBsAg, anti-HCV, syphilis serology.  

– Imaging: Chest X-ray, abdominal ultrasound.  

– Psychological Assessments: Depression (HDRS, Beck), anxiety (HARS, Zung), personality (EPI, MMPI), sleep (PSQI); pre/post-treatment. Optional: cognition (MMSE), stress-anxiety-depression (DASS), alcohol use (AUDIT), alcohol withdrawal (CIWA) if co-occurring alcohol use.  

– Functional Studies: ECG, EEG, cerebral blood flow, CT, MRI.

IV. TREATMENT  

1. Treatment Principles  

– Select therapy based on patient needs and facility capabilities.  

– Post-withdrawal, implement long-term maintenance to prevent relapse.  

– Employ a holistic approach addressing biological, psychological, and social factors, with close collaboration between healthcare providers, family, and community.  

– Withdrawal Management: Options include antipsychotics, clonidine, or psychotherapy.  

– Relapse Prevention: Naltrexone.  

– Substitution Therapy: Methadone or buprenorphine.  

– Treat co-occurring physical conditions.

2. Treatment Framework  

– Withdrawal management (various methods).  

– Maintenance therapy for relapse prevention (naltrexone).  

– Substitution therapy (methadone, buprenorphine).

3. Specific Treatments  

3.1. Withdrawal Management  

– Anxiolytics: Benzodiazepines (e.g., diazepam 5 mg tabs, oral/IM/IV).  

+ Priority use in first 1-2 days.  

+ Contraindications: Diazepam allergy, uncompensated respiratory failure, myasthenia gravis.  

+ Day 1-2: 20 mg (4 tabs) every 4 hours until agitation subsides and sleep occurs; resume if anxiety persists upon waking.  

+ Day 3-4: Reduce to 10 mg (2 tabs) every 6-8 hours.  

+ Day 5: Discontinue to avoid dependence (may extend in select cases).  

– Antipsychotics: Levomepromazine (25 mg tabs).  

+ Use for severe symptoms (e.g., agitation, complex sensations like “worms in bones”).  

+ Dosing: Initial 50 mg (2 tabs); after 1 hour, if no sedation and systolic BP ≥100 mmHg, give 100 mg (4 tabs); repeat 100 mg after 1 hour if needed; subsequent doses of 50 mg (2 tabs) every 2 hours if BP stable and symptoms persist.  

+ Stop when withdrawal resolves; monitor BP frequently.  

+ Combine with other antipsychotics for co-occurring emotional/behavioral disturbances if needed.  

– Analgesics: Paracetamol (0.5 g tabs).  

+ For severe muscle pain: 1 g (2 tabs) 2-3 times/24h, first 3 days.  

– Antispasmodics: Spasfon (80 mg tabs).  

+ For abdominal cramps: 160 mg (2 tabs) 2-3 times/24h.  

– Antidiarrheals/Dehydration Prevention:  

+ Spasfon as above for diarrhea/nausea due to increased gut motility.  

+ Oresol (oral glucose-electrolyte solution) for prolonged diarrhea/sweating causing dehydration.  

– Clonidine: 0.15 mg tabs.  

+ 0.075-0.15 mg/dose, repeated as needed (average 0.3-1.2 mg/day).  

+ Pause if BP <90/60 mmHg or pulse <60 bpm; resume after 30 minutes if stable.  

+ Maintain 3 days, taper from day 4, stop by day 10 if withdrawal resolves.  

+ Add diazepam (3-5 days) for insomnia/agitation, paracetamol for muscle pain if needed.  

– Fluids/Electrolytes: Ringer’s lactate, 0.9% NaCl, 5% glucose (1-2 L/day IV or Oresol orally).  

– Vitamins: B1, B6, B12.  

– Hepatic Support: Aminoleban, silymarin, boganic, branched-chain amino acids.  

– Nutrition: IV/oral supplementation.  

– Cognitive Enhancers.

3.2. Maintenance Therapy for Relapse Prevention  

– Naltrexone Protocol:  

+ Pre-Treatment Preparation:  

  + Clinical exam (general health, pregnancy in females).  

  + Labs: CBC, liver function (SGOT, SGPT), kidney function (urine protein), urine opioid test (chromatography/dipstick), naloxone challenge to confirm opioid-free status.  

+ Dosing:  

  + Day 1: 25 mg (½ tab); if no withdrawal after 30 minutes, add 25 mg (total 50 mg).  

  + Weeks 1-2/3: 50 mg/day (1 tab).  

  + Subsequent weeks (alternate-day):  

    + Option 1: Mon (50-100 mg), Wed (50-100 mg), Fri (50-150 mg).  

    + Option 2: Tue (50-100 mg), Thu (50-100 mg), Sat (50-150 mg).  

+ Monitoring:  

  + Urine opioid testing: First month (biweekly), then monthly; unscheduled if suspicion arises.  

  + Liver function every 3 months; stop if enzymes significantly elevate (physician discretion).  

  + Minimum duration: 12 months for effective relapse prevention.  

+ Side Effect Management:  

  + Insomnia/agitation: Diazepam 5-10 mg at bedtime.  

  + Abdominal pain: Alverine citrate (40 mg, 1-2 tabs/dose).  

  + Diarrhea: Oresol per instructions.  

  + Headache: Paracetamol (500 mg/dose).  

  + Nausea: Metoclopramide (10 mg/dose).  

  + Dizziness: Cinnarizine (25 mg/day).  

  + Fatigue: Vitamin/nutritional support, IV fluids.  

  + Hepatic support, cognitive enhancers.

3.3. Harm Reduction with Methadone  

– Induction Phase (2 weeks):  

+ Start 15-30 mg (low: 15-20 mg, medium: 20-25 mg, high: 25-30 mg); monitor closely at 25-30 mg.  

+ No dose increase in first 3 days unless severe withdrawal persists.  

+ Expect partial withdrawal relief; reduce dose if intoxication occurs.  

+ After 3-5 days, increase 5-10 mg/day if withdrawal persists (max 20 mg/week).  

– Adjustment Phase (Week 3 to 1-3 months):  

+ Monitor withdrawal and cravings; increase 5-15 mg/day every 3-5 days (max 30 mg/week).  

– Maintenance Phase:  

+ Effective dose eliminates cravings with minimal side effects (average 60-120 mg, minimum 15 mg/day).  

– Discontinuation:  

+ >40 mg/day: Reduce 10 mg/week.  

+ <40 mg/day: Reduce 5 mg/week or stop directly.  

– Missed Doses/Reinitiation:  

+ 1 day: No change.  

+ 2 days: Normal dose if no intoxication.  

+ 3 days: Normal dose after exam.  

+ 4 days: Half dose after exam.  

+ 5 days: Half dose per physician discretion.  

+ >5 days: Restart as new patient.  

– Monitoring:  

+ Clinical progress: High-risk behaviors, comorbidities, pregnancy.  

+ Urine testing: Adjust dose, detect illicit opioid use; consider cessation if persistent use despite counseling.  

+ Daily supervised dosing with healthcare, family, and community support.  

– Nutrition: Balanced, digestible, nutrient-rich diet across four food groups.  

– Community Rehabilitation: Occupational therapy.

V. PROGNOSIS AND COMPLICATIONS  

Opioid dependence is a chronic, progressive condition requiring prolonged treatment with multi-agency and community collaboration. The most common and severe complication is overdose, alongside risks of HIV, hepatitis B/C transmission.

VI. PREVENTION  

– Educate communities on the physical, mental, and social harms of opioids, steering youth toward healthy lifestyles.  

– Strictly regulate illegal opioid production, distribution, and use, while ensuring legal opioids are used appropriately.  

– Focus on high-risk groups: families with substance users, individuals in crisis, and psychiatric patients.

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