Managing acute opioid withdrawal with tramadol during COVID-19 lockdown in a peri-urban setting

Background: The coronavirus disease 2019 (COVID-19) has highlighted the scope of heroin dependence and need for evidence-based treatment amongst marginalised people in South Africa. Acute opioid withdrawal management without maintenance therapy carries risks of increased morbidity and mortality. Due to the high costs of methadone, Tshwane's Community Oriented Substance Use Programme (COSUP) used tramadol for opioid withdrawal management during the initial COVID-19 response. Aim: To describe demographics, route of heroin administration and medication-related experiences amongst people accessing tramadol for treatment of opioid withdrawal.Setting: Three community-based COSUP sites in Mamelodi (Tshwane, South Africa). Methods: A retrospective cross-sectional study was conducted. Data were collected using an interviewer-administered paper-based tool between April and August 2020. Descriptive statistics were used to analyse data. Results: Of the 220 service users initiated onto tramadol, almost half (n = 104, 47%) were not contactable. Fifty-eight (26%) people participated, amongst whom most were male (n = 55, 95%). Participants' median age was 32 years. Most participants injected heroin (n = 36, 62.1%). Most participants experienced at least one side effect (n = 47, 81%) with 37 (64%) experiencing two or more side effects from tramadol. Insomnia occurred most frequently (n = 26, 45%). One person without a history of seizures experienced a seizure. Opioid withdrawal symptoms were experienced by 54 participants (93%) whilst taking tramadol. Over half (n = 38, 66%) reported using less heroin whilst on tramadol. Conclusion: Tramadol reduced heroin use but was associated with withdrawal symptoms and unfavourable side effects. Findings point to the limitations of tramadol as opioid withdrawal management to retain people in care and the importance of access to first-line opioid agonists.

Psychosocially-Assisted Pharmacological Treatment of Opioid Dependent Adults: A Systematic Review

Background: Opioid dependence is a conundrum that significantly contributes to global mortality, crimes, and transmission of diseases such as hepatitis (B and C), human immunodeficiency virus and perhaps, coronavirus disease 2019 (COVID-19). There are contradictory findings on the efficacy of psychosocially-assisted pharmacological treatment of opioid dependence in adults. Objective: The overall objective of this research is to investigate if psychosocially-assisted pharmacological therapy has significantly better effect than pharmacological therapy with regards treatment outcomes of opioid dependent adults. Methods: All methods employed in this study are in conformity with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) framework for systematic review which involve identification, screening, eligibility and inclusion. This systematic review involved PubMed literature search on randomized controlled trials published between 1st January 2015 to 1st October 2021. Results: PubMed search yielded 5,216 articles which were screened using inclusion and exclusion criteria resulting in 19 articled being retained for data extraction. Of the 19 articles used in this study, 13 (68.4%) articles having a combined sample size of 1,928 (60.6%) showed that addition of psychosocial intervention to pharmacotherapy significantly improved abstinence from opioid abuse. Conclusion: The outcome of evaluation of the overall evidences presented in the 19 articles used in this study is that psychosocially-assisted pharmacological therapy is significantly better than pharmacological treatment with respect to enhancement of abstinence from opioid abuse among opioid-dependent adults. Additionally, this study has provided specific combinations of psychosocial and pharmacological treatment that can produce significant beneficial effect on opioid abstinence. The huge downturn in randomized controlled trials on treatment of opioid dependence among adults has been highlighted in this study.