Yes, people can die from opiate withdrawal

Yes, people can die from opiate withdrawal

It is generally thought that opiate withdrawal is unpleasant but not life-threatening, but death can, and does, occur. The complications of withdrawal are often underestimated and monitored inadequately. It is essential that clinical management programmes are put in place routinely in jails, prisons and other facilities where withdrawal is likely in order to avert these avoidable deaths.

Death is an uncommon, but catastrophic, outcome of opioid withdrawal. The complications of the clinical management of withdrawal are often underestimated and monitored inadequately. In this commentary we highlight the under-reported risk of death, discuss deaths that occurred during opioid withdrawal in United States and British custodial settings and explore implications for clinical management.

The opioid withdrawal syndrome is well-delineated [1]. Signs and symptoms include dysphoria, insomnia, pupillary dilation, piloerection, yawning, muscle aches, lacrimation, rhinorrhea, nausea, fever, sweating, vomiting and diarrhoea. For short-acting opioids, such as heroin, symptom severity peaks typically at around 2–3 days. The syndrome is generally characterized as a flu-like illness, subjectively severe but objectively mild, that stands in stark contrast to the life-threatening benzodiazepine and alcohol withdrawal syndromes. Indeed, it is often said and, was stated publicly by one prominent medical practitioner, that ‘…no one dies of opiate withdrawal’ [2].

How could someone die during opiate withdrawal? The answer lies in the final two clinical signs presented above, vomiting and diarrhoea. Persistent vomiting and diarrhoea may result, if untreated, in dehydration, hypernatraemia (elevated blood sodium level) and resultant heart failure. There are documented cases of such deaths occurring during the withdrawal process, all in jail settings, that date back to the late 1990s. In 1998, Judith McGlinchey was incarcerated in the United Kingdom and went into heroin withdrawal [3]. She exhibited persistent vomiting, sudden weight loss and dehydration. The cause of death was attributed to hypoxic brain damage caused by a cardiac arrest. A case of failure of duty of care was argued successfully before the European Court of Human Rights. Recent years have seen a number of similar cases reported in the public press between 2013 and 2016 that occurred in United States jails. We are aware of 10 such reported cases, six females and four males, ranging in age from 18 to 49 years [Supporting information, Appendix S1].

All such deaths are preventable, given appropriate medical management. In each case the process of death appeared prolonged, with ample time to treat the person successfully. Why, then, did they occur? These were cases of neglect, or a lack of medical resources to support the individual. Intravenous re-hydration, for instance, is not regarded as appropriate in non-health-care settings. There is a failure to identify the seriousness of the level of dehydration, and to assume that a quiet prisoner is a good prisoner. Jails process more drug withdrawals than any other single institution, but often do not have medical resources to manage severe withdrawal. Indeed, one study of US jails found that only a quarter had alcohol or drug detoxification services [4].

There is an urgent need to raise awareness of the risk of a fatal outcome in the presence of poor clinical governance. People can, and do, die from opiate withdrawal. The recent substantial increases in heroin use in the United States [5] make the management of heroin withdrawal a major clinical issue for the correctional system, as opiate users comprise more than a substantial proportion prison populations [6]. Moreover, as jails are the entry point to the correctional system, they are the most likely to have to deal with acute withdrawal among opioid-dependent inmates.

Can anything be done? Withdrawal protocols for jails exist in the United States [7]. Despite this, the medical management of withdrawal is often described as suboptimal by heroin-dependent inmates [8]. In the cases of the reported deaths in jails this was clearly so. Opiate withdrawal needs to be recognized within the correctional system, and elsewhere, as potentially life-threatening and managed accordingly. This is of particular importance for jails, which are short-stay, local facilities where a heroin user may be incarcerated within an hour of being arrested on the street.

An alternative to withdrawal is to provide opiate substitution therapy to opiate-dependent inmates entering the correctional system. The provision of treatment in such settings has been implemented successfully in many jurisdictions, and is associated with lower mortality rates and better clinical outcomes post-release than those who are opioid-dependent at entry and have an enforced withdrawal [9, 10]. One recent study reported that continued maintenance treatment was associated with a 93% reduction of risk of death in custody during a 10-year period [10]. Similar action providing effective drug treatment is required across custodial settings. This is particularly so for the United States, given the recent epidemic of heroin and opioid dependence, as the number of heroin users entering jails and prison will, in all probability, increase substantially in coming years.

Heroin withdrawal is not a trivial matter. The rising number of deaths from withdrawal in United States jails has received scant attention to date. Given appropriate clinical management, such deaths need not occur.

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