In a bit confused. i have a large number of opiate dependent patients who are being prescribed methadone by the local substance misuse service. The previous GP at my practice was very experienced in Substance Misuse and did use a lot of clonidine to prevent sweating. Does it work though? Do people in general prescribe it long term for people on methadone or is the consensus that it is a waste of time?? In the real world are its side effects likely to be a problem?
Also does it have any street value? Thanks for your thoughts

generally clonidine was seen as unsuitable for use in the community for Opiate detox due to its effect on blood pressure and was advised to be used on an inpatient basis only. Lofexidine which does not have such a marked effect was preferred.

Was this being prescribed in lower doses than the detox dose and if so does clonidine have the same effects on blood pressure at lower doses?

If you answered no for the first question then the prescribing was in theory unsafe, and if the answer to the second question is yes (sorry I haven't got the answer to this to hand) then again it is in theory unsafe.

It suppresses sweating in opiate withdrawal according to literature and observation, but there is nothing I can find about it in maintenance. That doesn't mean it doesn't though, but sweating in adequately maintained patients is usually due to different factors.

I would be extremely cautious about going down this route yourself.

This message has been edited. Last edited by: Jim Barnard,

Thanks for your thoughts Jim. much appreciated..Most of the patients are on 0.3mg once daily..They all insist that it works re their sweating and none of them report any dizzyness or signs of hypotension..Difficult to know what to do really..

the BNF says the maximum dose for clonidine is 1.2 mg per day so this is way below that. It is indicated in menopausal flushing as well as hypertension which is a bit closer to this use.

It does not recommend inpatient use only though, so maybe you're OK, and I can't find a dose regimen for opiate detox, so I can't compare the doses. Also no stated adverse interactions with opioids, however there are with anxiolytics/hypnotics.

I may be being over cautious.

It seems a bit unusual to use clonidine along with methadone maintainence.
Sweating is common but it isnt often troublesome enough to warrant prescribing another drug.
We have several hundred on methadone at my team but none on anything to control sweating.
B blockers e.g. atenolol can be used as an alternative.

I've given driclor to a couple of patients.

Thanks for your comments..It's interesting that nobody seems to use it much. I was under the impression from the number of people on it here, that it was fairly standard treatment in people on long term methadone maintainance. I have to say the patients seem to swear by it and I haven't seen any adverse effects

I know of no evidence that clonidine helps the excess sweating we see with opiate substitutes. We see the problem frequently and I think most users see that as an occupational hazard. The side effects of clonidine do not make it an intervention that I would use or the users seem to think useful.

Has anyone else read that the sweating with methadone is a histamine - mediated response? Or tried anti-histamines? I have - but not had much success.

The issue of sweating on methadone is a common problem. I have never heard of using clonidine to counteract this problem.

I have left a message with Dr Kim Wolff (Institute of Psychiatry/National Addiction Centre at the Maudsley)who may be able to shed some light on this...

If my memory serves me Colin Brewer used Clonadine during his inpatient detox, not sure about out patient use, I would have concerns re BP.
We dont use in our programme so I have no experience to offer.

Buscopan does have some impact on sweats, also useful for muscle spasm (both abdo & general) in my experience.

quote:

Originally posted by Sally Read:
Has anyone else read that the sweating with methadone is a histamine - mediated response? Or tried anti-histamines? I have - but not had much success.

Sally,
Yes it is related to histamine release. I've never tried anti-histamines.

Has anybody heard of a "clonidine buzz"? Or is there a market on the street for clonidine? I have recently had a client transferred because he had an altercation with his previous practice for overusing his "usual" 300mcg in 100mcg tablets, maintained long after he has purportedly stopped using heroin or MMT (not sure how accurate this history is) . I tried a compromise of multiples of 25mcg tablets in a lower doseage but he was not happy with this and he is now moving from doctor to doctor in the practice here, seeking satisfaction. Another experienced GP mentioned "the clonidine buzz" and said that, apart from being ineffective, this is why it had stopped being prescribed in his service.

interesting Jim - I have one patient who did a detox on clonidine in rehab, came out, relapsed after 6 months or so and went back on methadone. Then asked to use clonidine to reduce her methadone (we use lofexidene for this purpose on occasions, especially if on high doses and really helpful) and I agreed. She then kept requesting them and sort of developed a 'habit' on clonidine. I did literature search (and rang up manufacturers who or course said no problem with their drug) and found some interesting stuff
Psychiatric quarterly vol 72 number 2 June 2001 Sylvia Dennison conclusion was clonidine abuse among opiate users - seen to use to enhance opiate effect and prolong effect - most literature was US where use it lots more. They suggest not abrupt withdrawal but can't find many other problems with it so my dilemma was: is my patient better on 80mg methadone and clonidine or 200mg of methadone - her choice with the evidence was the later - do you agree?

Thanks Chris, that is interesting. He tells me that he is not currently using, but when I met him I had a feeling that this may not have been true, although I have nothing objective to base that feeling on. I don't have as much control or ability to get background info in that GP job as I do in the specialist misuse one. I doubt if he will opt to see me again, so I will put your info in the records to give the next doctor some insight into what may possibly be going on

Found the question and string very interesting, so did a little google searching.

First two articles I found were surveys on the 'unmet health needs' of those on OST. Winstock, Drug Alcohol Rev. 2008 Jul;27(4):393-7, described the results of a questionnaire for 508 patients receiving OST in Australia. Sweating came in as the second commonest symptom the clients wanted help with (affecting 26% of clients). Sheridan, Harm Reduction Journal 2005 Nov 13;2:25, found in a similar survey of methadone clients in New Zealand that the most commonly reported health problem they described was sweating, and it affected 70% of those surveyed. Maybe it's a bigger problem than we realise, and our clients are just not mentioning it to us.

On a more positive note Caflish, Am J Psychiatry 160:386-387, February 2003, presented case reports where those on methadone were given biperiden sucessfully to manage excesive sweating. Biperiden is an anticholinergic not used in the UK as far as I can see, but the author said 'Little is known about the exact mechanisms by which methadone influences autonomic thermoregulatory control and produces increased sudomotor activity (I think that means sweating to you and me!). However, the mainly centrally acting antimuscarinic agent biperiden appears to antagonize this overactivation very efficiently'. Maybe there's scope for prescribing an equivalent anticholinergic for anyone who has really bad sweating while on methadone.

Caflish also went on to say that it is possible that very bad sweating might cause drop outs from treatment.

Perhaps we should be more aware of it as a problem for methadone users