Indian Journal of Palliative Care
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Table of Contents 
LETTER TO EDITOR
Year : 2019  |  Volume : 25  |  Issue : 1  |  Page : 165-166

Nonpharmacological modality of treating opioid withdrawal


Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

Date of Web Publication31-Jan-2019

Correspondence Address:
Dr. Abhijit S Nair
Department of Anaesthesiology, Basavatarakam Indo.American Cancer Hospital and Research Institute, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPC.IJPC_116_18

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How to cite this article:
Nair AS. Nonpharmacological modality of treating opioid withdrawal. Indian J Palliat Care 2019;25:165-6

How to cite this URL:
Nair AS. Nonpharmacological modality of treating opioid withdrawal. Indian J Palliat Care [serial online] 2019 [cited 2019 Feb 20];25:165-6. Available from: http://www.jpalliativecare.com/text.asp?2019/25/1/165/251064


Sir,

Opioid dependence is an alarming situation when a person is physiologically and psychologically addicted to an opioid.[1] Opioid withdrawal is characterized by pupillary dilatation, severe muscle cramps, profuse diarrhea, abdominal cramps, yawning, piloerection, rhinorrhea, lacrimation, hypertension, tachycardia, temperature dysregulation, dementia, and delirium.[2] Opioid withdrawal manifests in a palliative care patient if the opioid is not available on time or patient who was earlier dependent on it has stopped using it. Reason for stopping of opioid could be interruption of supply, financial issues, or due to intolerable adverse effects. Another reason of manifestation of withdrawal is when a route of administration of an opioid is changed (for example, tablet morphine is now changed to transdermal fentanyl patch for better patient compliance).

Recently, lofexidine which is an alpha-2 receptor agonist marketed as oral formulation has been approved for managing opioid withdrawal.[3] The drug has to be judiciously prescribed owing to its pharmacological profile as it causes hypotension and bradycardia in susceptible patients. The US-FDA has recently approved auricular neurostimulation device which is nonpharmacological modality for treating opioid withdrawal. The device is specific, safe, and flexible to use. The device is fitted to the ear which sends electrical impulses. The device can be used for a maximum of 5 days.

The auricular branches of V, VII, IX, and X cranial nerves innervating the ear are connected to the brainstem, especially to the nucleus tractus solitarius (NTS). The auricle is considered as gateway to the brain as it is innervated by cranial nerves which are targeted in neurostimulation. Amygdala is responsible for the negative emotional state of withdrawal to opioids and drug craving. The auditory neurostimulation device modulates NTS which interferes with the impulses and mediators reaching hypothalamus, amygdala, and rostral ventral medulla. In this way, neuromodulation of limbic system helps in reducing symptoms occurring due to opioid withdrawal.[4]

At this moment, it is not understood if the device has any effect on other mediators released during opioid withdrawal such as norepinephrine, adrenocorticotropic hormone, cortisol, and endorphins. Preliminary studies have shown that this device reduced clinical opioid withdrawal scale score by 63% in initial 20 min itself and 84.6% in 60 min without any rescue medication.[5] The device claims to help in detoxification and later facilitate rehabilitation of patient-facing opioid withdrawal. The device is available in the market with the brand name Drug Relief™ marketed by DyAnsys® Private Ltd.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nicholls L, Bragaw L, Ruetsch C. Opioid dependence treatment and guidelines. J Manag Care Pharm 2010;16:S14-21.  Back to cited text no. 1
    
2.
Das S, Sah D, Nandi S, Das P. Opioid withdrawal presenting as delirium and role of buprenorphine: A case series. Indian J Psychol Med 2017;39:665-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Available from: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm607884.htm. [Last updated on 2018 May 16].  Back to cited text no. 3
    
4.
Mercante B, Deriu F, Rangon CM. Auricular neuromodulation: The emerging concept beyond the stimulation of vagus and trigeminal nerves. Medicines (Basel) 2018;5. pii: E10.  Back to cited text no. 4
    
5.
Miranda A, Taca A. Neuromodulation with percutaneous electrical nerve field stimulation is associated with reduction in signs and symptoms of opioid withdrawal: A multisite, retrospective assessment. Am J Drug Alcohol Abuse 2018;44:56-63.  Back to cited text no. 5
    




 

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