# Hard Drug Abuse or Addiction - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class PS16.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care · Substance Use Disorder - StatPearls - NCBI Bookshelf (NBK570642) - https://www.ncbi.nlm.nih.gov/books/NBK570642/ · Hard Drug Abuse or Addiction - disease-level clinical article (hard-drug-abuse-full.txt) · WHO Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (Geneva: WHO; 2009, ISBN 978-92-4-154754-3), chapter 6 - Patient level guidelines (NCBI Bookshelf NBK143185) - https://www.ncbi.nlm.nih.gov/books/n/whoopioid/ch6/ (who-opioid-dependence-2009-ch6.txt) - Verified date: 2026-08 ## Verified against - No dose - referral pathway, no medicine given in primary care - Hard Drug Abuse or Addiction - disease-level clinical article (hard-drug-abuse-clinical.txt) - Hard Drug Abuse or Addiction - disease-level clinical article (hard-drug-abuse-full.txt) - WHO Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (Geneva: WHO; 2009, ISBN 978-92-4-154754-3), chapter 6 - Patient level guidelines (NCBI Bookshelf NBK143185) (who-opioid-dependence-2009-ch6.txt) ## Treatment metadata - Recognise, harm-reduce, refer to addiction services (Recognition & Referral) - Methadone — oral.liquid - Buprenorphine — mouth ## Complete treatment card ```text HARD DRUG ABUSE OR ADDICTION Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class PS16.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care · Substance Use Disorder - StatPearls - NCBI Bookshelf (NBK570642) - https://www.ncbi.nlm.nih.gov/books/NBK570642/ · Hard Drug Abuse or Addiction - disease- level clinical article (hard-drug-abuse-full.txt) · WHO Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (Geneva: WHO; 2009, ISBN 978-92-4-154754-3), chapter 6 - Patient level guidelines (NCBI Bookshelf NBK143185) - https://www.ncbi.nlm.nih.gov/books/n/whoopioid/ch6/ (who-opioid-dependence-2009-ch6.txt) Review status: REVIEWED against No dose - referral pathway, no medicine given in primary care, Hard Drug Abuse or Addiction - disease-level clinical article (hard-drug- abuse-clinical.txt), Hard Drug Abuse or Addiction - disease-level clinical article (hard-drug-abuse-full.txt), WHO Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (Geneva: WHO; 2009, ISBN 978-92-4-154754-3), chapter 6 - Patient level guidelines (NCBI Bookshelf NBK143185) (who-opioid- dependence-2009-ch6.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (3) - Cocaine or other stimulant use typically brings on anxiety and, in some cases, psychosis [anxiety] - A patient who has developed tolerance often presents needing a larger dose or requesting an early refill - Patients who are dependent show physical withdrawal symptoms and do not feel normal without the drug SIGNS - what you find (2) - Exam in stimulant intoxication typically shows a fast heart rate, fast breathing, and high blood pressure [hypertension · tachycardia · tachypnoea] - Opioid intoxication shows the opposite pattern on exam - slow heart rate, low blood pressure, pinpoint pupils, low temperature, and sedation [bradycardia · hypotension] TESTS (3) - Cocaine users may need serial troponin testing since coronary vasoconstriction commonly elevates troponin levels - Kratom and bath salts often do not show up on a routine urine drug screen and require specialised testing such as mass spectrometry - The Addiction Severity Index screens seven domains including medical, employment, drug and alcohol use, legal, social, and psychiatric status IF NOT THIS - what else fits (2) - More than half of patients with substance use disorder also have bipolar disorder - PTSD commonly co-occurs with alcohol abuse and should be screened for in every patient with addiction Source StatPearls "Drug Addiction" - disease-level clinical article Status traced to the source above Rx: Main treatment | Opioid agonist maintenance - licensed addiction service only, dosing supervised | Opioid agonist maintenance - second line to methadone, licensed addiction service only MAIN TREATMENT 1. RECOGNISE, HARM-REDUCE, REFER TO ADDICTION SERVICES (RECOGNITION & REFERRAL)[1st line] Adult Dependence on substances such as heroin, cocaine or amphetamines. The definitive management is a programme, not a prescription: the article makes rehabilitation the cornerstone of treating addiction, from sobering a patient through to keeping them in remission, and has drug treatment working only in combination with non-drug methods - both for effect and to stop use progressing into misuse and then dependence. Build the plan with the patient; the article is explicit that a joint plan drawing on the patient's own input produces better results. Acute presentations are stabilised first, monitoring and maintaining the vital signs, with what is done depending on the stage the patient presents at and on the substance involved. Refer to a specialist addiction service for supervised withdrawal or substitution therapy; offer harm reduction, bloodborne-virus testing and vaccination meanwhile. - Refer, with advice Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why Dependence on substances such as heroin, cocaine or amphetamines. The definitive management is a programme, not a prescription: the article makes rehabilitation the cornerstone of treating addiction, from sobering a patient through to keeping them in remission, and has drug treatment working only in combination with non-drug methods - both for effect and to stop use progressing into misuse and then dependence. Build the plan with the patient; the article is explicit that a joint plan drawing on the patient's own input produces better results. Acute presentations are stabilised first, monitoring and maintaining the vital signs, with what is done depending on the stage the patient presents at and on the substance involved. Refer to a specialist addiction service for supervised withdrawal or substitution therapy; offer harm reduction, bloodborne-virus testing and vaccination meanwhile. Caution RED FLAG - Cocaine intoxication/addiction can cause myocardial ischemia, psychosis, and fatal arrhythmias requiring acute emergency management, not just harm-reduction counselling and referral. RED FLAG - Opioid intoxication is recognised by the opposite picture to a stimulant, and the danger is the sedation. Where cocaine and the other stimulants drive the sympathetic side, opioids produce the parasympathetic one: a slow pulse, a low blood pressure, small pupils, a low temperature and sedation. It is the sedation that kills, by depressing the breathing. (Drug Addiction - StatPearls - NCBI Bookshelf, NBK549783) Substitution therapy is a licensed service's prescription, never a clinic's. Methadone and buprenorphine maintenance are the mainstay of opioid use disorder and both are controlled drugs given under supervision - the article names the setting and no drug and no dose for it, describing the range of public and private services set up since the 1960s: methadone clinics, outpatient programmes provided free, and residential treatment in the community. The WHO regimens are set out on the methadone and buprenorphine options below so that a dose can be recognised and questioned; refer, do not initiate. The article's own pharmacology section is about two OTHER substances, which is why nothing in it treats heroin, cocaine or amphetamine dependence. It offers drug treatments for the 2 addictions that are commonest - tobacco and alcohol - naming disulfiram, naltrexone and acamprosate for alcohol dependence, and bupropion and varenicline for tobacco. It states no dose for any of them. Those regimens live on the Alcoholism and Smoking Cessation cards, where they belong, and the opioid agonist doses shown here come from WHO instead. RED FLAG - Overdose with respiratory depression or reduced consciousness (emergency), signs of withdrawal needing medical supervision, or injecting-related infection such as an abscess, endocarditis, or bloodborne virus exposure. OPIOID AGONIST MAINTENANCE - LICENSED ADDICTION SERVICE ONLY, DOSING SUPERVISED 2. METHADONE [1st line] Adult Prescribed and dispensed by a licensed opioid-treatment service, not started in a primary-care clinic. WHO's induction ceiling: the first daily dose turns on how neuroadapted the patient is, and should generally not exceed 20 mg - and under no circumstances 30mg. The climb after that is slow; WHO asks for the rate to be assessed individually and to be generally no greater than 10 mg every few days. For maintenance it puts the average range at 60-120 mg per day. It also names the formulation, recommending the oral solution for opioid dependence because supervising its administration is easier. - Open-ended. WHO treats opioid agonist therapy as having no set endpoint, to be continued for as long as there is a clinical reason to. Peds No weight-based dose. Adolescents are treated in dedicated services: WHO notes that their treatment needs are particular, and that services aimed directly at them often serve adolescents with opioid dependence better. Source WHO Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (Geneva: WHO; 2009, ISBN 978-92-4-154754-3), chapter 6 - Patient level guidelines (NCBI Bookshelf NBK143185), sections 6.3.1, 6.3.3, 6.3.5 and 6.3.7 (who- opioid-dependence-2009-ch6.txt) Why The indication is WHO's own: agonist maintenance treatment is for every patient who is opioid dependent, able to give informed consent, and has no specific contraindication to it. Between the two agonists WHO puts methadone first - it advises most patients onto methadone at an adequate dose in preference to buprenorphine (strong recommendation, high-quality evidence) - because it retained more patients in treatment and costs less. The numbers are printed so that a doctor seeing a patient already in a programme can recognise a dose that is out of range and talk to the service about it; the prescription itself stays with the service. Egypt registers no methadone product of any kind, so no brand and no price can be shown. Caution The first two weeks are the dangerous ones. WHO puts the highest risk of overdose in the opening fortnight of methadone treatment, because there is no certain way to gauge how neuroadapted the patient already is. Dosing is watched at the start. WHO's recommendation is that methadone and buprenorphine be given under direct supervision through the early phase. Doses to take home come later, and only where attending less often is judged to be worth more than the risk of the drug being diverted - a judgement kept under regular review. Unsupervised methadone kills people it was never prescribed for. The figures on diversion and on overdose deaths point the same way every time: methadone given without supervision is dangerous, and a substantial number of the resulting overdose deaths are in people it was never prescribed to. QT prolongation, and more of it at higher doses. WHO reports that methadone appears to lengthen the QT interval, and that cardiac arrhythmias have been reported with it. There seems to be a small rise in the risk of a life-threatening arrhythmia on methadone which buprenorphine does not carry, and a high methadone dose may raise the risk of QT prolongation further. A benzodiazepine on top of an agonist raises the overdose risk. WHO says to give one to an outpatient on opioid agonist maintenance only with care: there is little evidence behind using these drugs long term, and they make a sedative overdose more likely. Where one is prescribed, it should come from one practitioner alone, and be dispensed, if it can be, at the same moment as the methadone dose is taken. In pregnancy methadone is the agonist of choice and it is not stopped. WHO regards agonist maintenance with methadone as the most suitable treatment for a woman who is pregnant or breastfeeding, and a pregnant woman already on it should be encouraged to stay on it rather than come off. The dose may have to rise: through the second and third trimester more methadone can be needed, as the metabolism speeds up and the circulating blood volume grows. CONTROLLED DRUG, and Egypt registers no methadone product at all. The whole supply runs through a licensed addiction service under narcotic regulations; a clinic without that authority refers rather than prescribes. Egypt no Egyptian brand matched - prescribe by generic name OPIOID AGONIST MAINTENANCE - SECOND LINE TO METHADONE, LICENSED ADDICTION SERVICE ONLY 3. BUPRENORPHINE [2nd line] Adult Sublingual tablet, prescribed and dispensed by a licensed opioid-treatment service. The first dose waits for withdrawal to start: WHO asks the patient to be in mild opioid withdrawal before taking it - generally at least 12 hours since the last heroin or other short-acting opioid - so that buprenorphine does not precipitate withdrawal. A heavily neuroadapted patient may do better on a lower initial dose of 2 mg, while moderate neuroadaptation will generally tolerate 4-8 mg a day to begin with. For maintenance WHO sets a floor rather than a target: an average of at least 8 mg per day. Where illicit use continues it asks for the dose to be raised by 4-8 mg, up to a limit of 32 mg daily. - Open-ended. WHO treats opioid agonist therapy as having no set endpoint, to be continued for as long as there is a clinical reason to. Peds No weight-based dose. Adolescents are treated in dedicated services: WHO notes that their treatment needs are particular, and that services aimed directly at them often serve adolescents with opioid dependence better. Source WHO Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (Geneva: WHO; 2009, ISBN 978-92-4-154754-3), chapter 6 - Patient level guidelines (NCBI Bookshelf NBK143185), sections 6.3.1, 6.3.3, 6.3.6 and 6.3.7 (who- opioid-dependence-2009-ch6.txt) Why Same indication as methadone: agonist maintenance treatment is for every patient who is opioid dependent, able to give informed consent, and has no specific contraindication. WHO places buprenorphine second - it treats high-quality methadone provision as the optimal treatment, holding buprenorphine as second-line where methadone is unwanted, inappropriate or ineffective. Its own list of reasons to choose it anyway: a previous response to buprenorphine or a failure to respond to methadone; methadone acting too briefly, so withdrawal appears between doses; methadone interacting with the patient's other medicines; a specific adverse effect of methadone; what treatment is available; and what the patient prefers. Its long action helps a stretched service - WHO notes that about two thirds of patients can take it every second or third day, which cuts the need for daily supervision. Egypt registers no buprenorphine product, so no brand and no price can be shown. Caution Given too early it precipitates withdrawal. WHO notes that in a patient heavily neuroadapted to opioids, buprenorphine can bring withdrawal on at the outset, and that such a patient may do better starting lower, at 2 mg. Dosing is watched at the start, and watching a sublingual tablet is harder than watching a swallowed liquid. WHO asks for methadone and buprenorphine both to be given under direct supervision in the early phase, and points out that supervising buprenorphine does not settle the problem of misuse: a sublingual tablet can take as long as 15 minutes to dissolve, and is hard to watch properly for that long. WHO's own practical method is to dispense the tablet into a clean container, tip it into the patient's mouth beneath the tongue, and look from time to time - it should be there, part dissolved. Diversion and injection are the characteristic failure. WHO warns that buprenorphine tablets are readily misused, and that injecting diverted tablets keeps the dependence going, passes on bloodborne viruses, and kills when the drug meets another sedative. A patient who has injected it should be on methadone instead - where there is a history of injecting buprenorphine, whether prescribed or bought, methadone maintenance is chosen over it. Deaths happen when it is combined with sedatives. WHO records deaths where buprenorphine was taken together with other sedatives; and on benzodiazepines during maintenance, its instruction is to proceed carefully, since little evidence supports using them long term and they raise the risk of a sedative overdose. WHO on the ordinary adverse effects: headache, constipation, disturbed sleep and anxiety are the common ones with buprenorphine, and it does not appear to lengthen the QT interval to any degree that matters. In pregnancy methadone is preferred, but a woman already stable on buprenorphine is not switched for the sake of it. WHO's preference for methadone rests on how much longer its safety in pregnancy has been observed. Where a woman is doing well on buprenorphine, the worth of staying on a treatment that is working weighs in the decision too. CONTROLLED DRUG, and Egypt registers no buprenorphine product at all. The whole supply runs through a licensed addiction service under narcotic regulations; a clinic without that authority refers rather than prescribes. Egypt no Egyptian brand matched - prescribe by generic name Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)