How should I approach the management of a patient presenting with opioid dependence in a primary care environment?

Approach to managing opioid dependence in primary care:

• Engage the patient in informed decision-making: Provide detailed information about opioid withdrawal symptoms, risks of detoxification, and the importance of ongoing support to obtain informed consent and promote shared decision-making.
• Assess for co-dependencies: Screen for alcohol and benzodiazepine dependence, as these may require concurrent or prior detoxification interventions.
• Pharmacological treatment: Offer methadone or buprenorphine as first-line detoxification medications, considering patient preference and prior maintenance treatment. Lofexidine may be considered for those opting out of these or with mild dependence. Avoid routine use of clonidine or dihydrocodeine.
• Detoxification regimen: Tailor the starting dose, duration (up to 12 weeks in community settings), and regimen based on severity of dependence, stability, and setting.
• Non-pharmacological support: Advise on lifestyle factors such as balanced diet, hydration, sleep hygiene, and exercise to support detoxification.
• Psychosocial interventions: Consider contingency management to reinforce abstinence and positive behaviours during and up to 3–6 months after detoxification.
• Ongoing monitoring and support: Provide continued treatment and psychosocial support to maintain abstinence and address comorbidities, reducing risk of relapse and overdose.

This approach aligns with NICE guidelines and Department of Health and Social Care recommendations for opioid detoxification in community settings.