From the Guidelines
Buprenorphine-naloxone is the most effective medication for ASAM detox, particularly for opioid detoxification, due to its ability to reduce withdrawal symptoms and improve treatment retention, as evidenced by a 2020 study published in the Annals of Emergency Medicine 1. The choice of medication for ASAM detox depends on the substance being used, with different medications being more effective for different substances. For opioid detoxification,
- buprenorphine-naloxone (starting at 4/1mg and titrating to 12-16mg daily)
- methadone (starting at 20-30mg and increasing by 5-10mg daily to a stabilizing dose of 60-120mg) are the most effective options, according to a 2020 study published in the Annals of Emergency Medicine 1.
- Clonidine (0.1-0.2mg every 6 hours) can help manage autonomic symptoms across multiple withdrawal syndromes. Adjunctive medications often include
- antiemetics like ondansetron,
- anti-inflammatories, and
- sleep aids. The medication choice should be individualized based on
- withdrawal severity,
- comorbidities, and
- patient history. These medications work by either directly replacing the substance effect (substitution therapy) or by managing specific withdrawal symptoms through action on neurotransmitter systems disrupted during chronic substance use. Proper medical supervision is essential during detoxification to
- monitor vital signs,
- adjust dosing, and
- address complications, as recommended by the American College of Physicians in a 2017 position paper 1.
From the FDA Drug Label
Methadone Hydrochloride Injection for Treatment of Opioid Dependence Detoxification and Maintenance Treatment of Opioid Dependence For detoxification and maintenance of opiate dependence, methadone should be administered in accordance with the treatment standards cited in 42CFR Section 8. 12, including limitations on unsupervised administration.
The best medication for ASAM detox is methadone, as it is indicated for the treatment of opioid dependence in detoxification or maintenance programs 2. However, it should be administered in accordance with the treatment standards cited in 42CFR Section 8.12, including limitations on unsupervised administration.
- Methadone should be used only for patients who are unable to take oral medication, such as during hospitalization.
- The patient's oral methadone dose should be converted to an equivalent parenteral dose using the considerations above.
- Methadone dosing should not be based solely on conversion tables, but rather individualized to account for the patient's prior opioid exposure, general medical condition, concomitant medication, and anticipated breakthrough medication use 2.
- Methadone products when used for the treatment of opioid addiction in detoxification or maintenance programs, shall be dispensed only by opioid treatment programs certified by the Substance Abuse and Mental Health Services Administration and approved by the designated state authority 2.
From the Research
Medications for ASAM Detox
The American Society of Addiction Medicine (ASAM) detox involves the use of medications to manage opioid withdrawal. The following medications have been studied for their effectiveness in ASAM detox:
- Buprenorphine: a partial opioid agonist that has been shown to be effective in managing opioid withdrawal 3, 4, 5, 6
- Methadone: a full opioid agonist that has been used for decades to manage opioid withdrawal, but its use is often limited due to its potential for abuse and side effects 3, 4
- Clonidine: an alpha-2 adrenergic agonist that has been used to manage opioid withdrawal, particularly in patients who are unable to tolerate buprenorphine or methadone 3, 7
- Tramadol: a synthetic opioid agonist that has been studied as a potential treatment for opioid withdrawal, but its effectiveness is still uncertain 5
- Lofexidine: a structural analogue of clonidine that has been shown to be effective in managing opioid withdrawal with fewer side effects than clonidine 7
Comparison of Medications
Studies have compared the effectiveness of these medications in managing opioid withdrawal:
- Buprenorphine vs. methadone: buprenorphine and methadone appear to be equally effective in managing opioid withdrawal, but buprenorphine may have a faster onset of action and fewer side effects 3
- Buprenorphine vs. clonidine: buprenorphine is more effective than clonidine in managing opioid withdrawal, with a lower average withdrawal score and higher treatment completion rates 3
- Tramadol vs. buprenorphine: tramadol may be comparable to buprenorphine in managing mild to moderately severe heroin withdrawal, but more studies are needed to confirm this finding 5
Psychosocial Interventions
Psychosocial interventions, such as counseling and behavioral therapy, can be effective in combination with pharmacological treatments for opioid detoxification 4. These interventions can help patients complete treatment, reduce substance use, and improve health and social status.