HIV/AIDS Treatment and Care : Clinical protocols for the European ...

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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
° methadone (stabilize on 40–60 mg once daily (OD) and reduce by 5 mg per week over 8–10
weeks);
° buprenorphine (stabilize on 8–10 mg OD and reduce over 5-6 weeks);
° clonidine; 14 and
° lofexidine (stabilize on 1.2–2.0 mg in divided doses (e.g. four times daily (QID)) and reduce
over 2 to 3 weeks).
When used appropriately, the medications above can produce safe and less uncomfortable withdrawal,
but the majority of patients will relapse into opioid use after withdrawal, regardless of
the method or substance used. Relapse rates following detoxification can be reduced by offering
after-care support with antagonist therapy, such as naltrexone at 50 mg per day, or 100 mg on day
1, 100 mg on day 3 and 150 mg on day 5. Given that one of the principal problems of naltrexone is
compliance (72), some services supervise ingestion in the after-care period.
2.3. Other treatment options
In addition to OST, treatment and management options include:
• self-help groups
• therapeutic communities15 • residential rehabilitation16 • psychological interventions such as:
° cognitive behavioural therapy (CBT) 17
° motivational interviewing18
° contingency management19 ° matrix model20
° relapse prevention strategies, medical or psychological
• peer support programmes
• social skills training
• vocational training
• heroin replacement treatment (heroin, morphine).
Heroin-assisted treatment was recently shown to be of more benefit to long-time opiate injectors
with unsuccessful abstinence-oriented and perhaps OST treatment histories who may have serious
continuing medical problems (77). However, heroin prescribing programmes remain highly controversial.
Such an intervention might be considered when all other treatment services have been
saturated, for example, where there is universal access to methadone and buprenorphine treatment.
2.4. Management of non-opioid dependence (including cocaine and ATS)
While it is estimated that there are now over 13 million injecting drug users worldwide, not all
substance dependence is on opioids. It is also associated with sedatives, cocaine and ATS. It is vital
that services respond to the needs of non-opioid users. HIV risk is also associated with non-opioid
drugs, particularly where these drugs are injected. There are limited data on association between
14 An alpha-adrenergic agonist that suppresses withdrawal signs and symptoms. The patient may require admission, given the
associated risk of significant hypotension; consequently lofexidine may be preferable.
15 Residential drug-free rehabilitation programmes of 3–15 months duration. Group or individual psychotherapy and vocational
training may be available.
16 Short-term residential programmes (6–8 weeks), often based on the 12-step Minnesota model.
17 A time-limited, structured, goal-oriented psychological intervention focusing on the problems of the drug user entering treatment.
The therapy identifies the determinants or high-risks of drug use and allows the user to relearn appropriate coping skills,
leading to a healthier lifestyle; can be brief or extended (73).
18 Stimulates and enhances an individual’s resolve to change behaviour.
19 An intervention that reinforces or rewards appropriate behaviour. The reward may be in the form of vouchers for samples that
test negative for drugs (74, 75).
20 Designed to integrate interventions into a comprehensive approach. Elements include: individual counselling, CBT, motivational
interviewing, family education groups, urine testing and participation in 12-step programmes (76).