Detoxification buprenorphine

Kleber HD, Weissman MM, Rounsaville BJ, et al Imipramine as treatment for depression in addicts. Arch Gen Psychiatry 40 649-633, 1983 Kleber HD, Riordan CE, Rounsaville BJ, et al Clonidine in outpatient detoxification from methadone maintenance. Arch Gen Psychiatry 42 391-394, 1983 Kleber HD, Topazian M, Gaspari J, et al Clonidine and naltrexone in the outpatient treatment of heroin withdrawal. Am J Drug Alcohol Abuse 13 1-17, 1987 Kornetsky C. Brain stimulation reward, morphine-induced stereotypy, and sensitization implications for abuse. Neurosci Biobehav Rev 27 777-786, 2004 Kosten TR, Kleber HD Buprenorphine detoxification from opioid dependence a pilot study. Life Sci 42 633-641, 1988... 

Horspool MJ, Seivewright N, Armitage CJ, Mathers N. Post-treatment outcomes of buprenorphine detoxification in community settings a systematic review. Eur Addict Res 2008 14(4) 179-85. 

Substitution therapy with methadone or buprenorphine has been veiy successfiil in terms of harm reduction. Some opiate addicts might also benefit from naltrexone treatment. One idea is that patients should undergo rapid opiate detoxification with naltrexone under anaesthesia, which then allows fiuther naltrexone treatment to reduce the likelihood of relapse. However, the mode of action of rapid opiate detoxification is obscure. Moreover, it can be a dangerous procedure and some studies now indicate that this procedure can induce even more severe and long-lasting withdrawal symptoms as well as no improvement in relapse rates than a regular detoxification and psychosocial relapse prevention program. 

Cheskin LJ, Fudala PJ, Johnson RE A controlled comparison of buprenorphine and clonidine for acute detoxification from opioids. Drug Alcohol Depend 36 115-121, 1994... 

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Sporadic use (e.g., for the induction of sleep after a psychostimulant binge) does not require specific detoxification. Sustained use can be treated as described in the previous sections on detoxification from therapeutic or high dosages but with added caution. In mixed opioid and benzodiazepine abuse, the patient should be stabilized with methadone (some clinicians use other oral preparations of opioids) and a benzodiazepine. Buprenorphine should not be administered with benzodiazepines, because a pharmacodynamic interaction is possible (Ibrahim et al. 2000 Kilicarslan and Sellers 2000) and fatalities have been reported with the combination (Reynaud et al. 1998). Sedative-hypnotic withdrawal is the more medically serious procedure, and we usually... 

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Naltrexone (ReVia). Naltrexone is a very potent antagonist of the actions of opiates. It has been used to reduce the rewarding effects of not only opiates but alcohol as well. Like buprenorphine, naltrexone appears to reduce craving for opiates by blocking their pleasurable effects. Naltrexone is not useful for detoxification and in fact worsens withdrawal. Naltrexone can be useful for maintenance treatment in those patients motivated to achieve total abstinence. It is taken at a constant dose of 50mg/day. A sustained-release depot formulation currently under development will likely help to overcome adherence issues that often undermine treatment for substance use disorders. 

Outcomes in time-limited methadone treatment have generally been found to be very poor in comparison with maintenance (McGlothin Anglin 1981, Gossop et al. 2001, Magura Rosenblum 2001), although the early influential studies were typically in established maintenance candidates who had treatment restricted, rather than individuals who chose to reduce as an option within a flexible policy. For our purposes this intermediate duration of treatment, which now applies just as much to buprenorphine, is classed as slow detoxification, and is discussed in the section on detoxification from the two medications. 

Further situations in which methadone can seem an unsatisfactory substitution agent are towards the other end of the treatment spectrum. In uncomplicated maintenance treatment or for detoxification, the criticisms which are levelled at methadone relate not so much to the subjective effects, but to the aspects of addictiveness, abuse potential and toxicity. The issue of whether methadone is too addictive to be really suitable for detoxification is considered in detail in Chapter 3, and the controversial subject of methadone risks and deaths in Chapter 1. It is in the relatively milder cases of heroin dependence that buprenorphine treatment as an alternative to methadone has risen to great prominence in several countries, although, importantly, the condition definitely does not have to be mild for this medication to be used. Undoubtedly the introduction of buprenorphine is one of... 

Individuals who are more heavily dependent on opiates clearly also require detoxification at various stages, and the remainder of the chapter discusses other forms of withdrawal treatment. As indicated in Chapter 1, community detoxification with methadone, as opposed to maintenance, is not well supported by evidence, but nevertheless this has been a standard treatment in the UK and other countries for many years. Meanwhile the almost certainly milder withdrawal symptoms from buprenorphine make this a more attractive proposition than methadone in detoxification, and the major impact made recently by this treatment will be examined. The last section discusses relapse prevention, focusing on counselling approaches and on the use of the opiate antagonist naltrexone, which we recommend after most detoxifications from opiates. 

Another complication which can be expected in a methadone detoxification, seemingly more even than in other methods, is that of mood disturbances. In a comparison of methadone and buprenorphine withdrawal courses, actually in addition to carbamazepine, Seifert et al. (2005) found more tiredness, sensitivity in mood and depression in the (randomly assigned) methadone patients, which situation can lead to either tranquillizers or antidepressants being considered. 

As mentioned earlier in the chapter, in the UK lofexidine is far more frequently selected in opiate detoxification than clonidine because of its better safety for outpatients, and a large comparative study of this and buprenorphine was carried out by Raistrick et al. (2005). Two hundred and ten patients were randomized, and the same comparisons in standard drug misuse outcomes and satisfaction measures were also studied in 271 individuals who did not wish to be in the randomized study. Many outcomes were similar with the two medications, but 65% of buprenorphine patients completed detoxification against 46% of those on lofexidine. That study was an example of one which included a follow-up to see whether patients had been abstinent after detoxification, with this being the case at the measurement point of one month for 38% of lofexidine completers and 46% with buprenorphine. This important aspect of whether successful detoxification does indeed lead to further abstinence has attracted attention in several buprenorphine studies, as reviewed by Horspool et al. (2008). Across five qualifying studies, they found detoxification completion rates of 65 to 100%, but low rates of abstinence at follow-up points, with more patients having returned to opioid maintenance than had complied with naltrexone. 

A one-month follow-up was included in a study by Breen et al. (2003) which used buprenorphine for detoxification as a transfer from methadone, with a 31% abstinence rate at that point. This investigation was also of interest as an illustration of much longer... 

As indicated, buprenorphine can offer a quicker option than methadone, with a three-day course reported to be effective for withdrawal from heroin (Cheskin et al. 1994). The side-effects of clonidine which render it unsuitable for community treatment can be manageable in the inpatient setting, although the drug is being superseded by lofexidine where that is available. Controlled studies have found clonidine and lofexidine to be equally effective in alleviating withdrawal symptoms in inpatient detoxification from heroin (Lin et al. 1997) and from methadone (Khan et al. 1997), with lofexidine resulting in less hypotension and fewer adverse effects. Another double-blind controlled study found lofexidine to be broadly as effective as a ten-day methadone detoxification in inpatient opiate withdrawal (Bearn et al. 1996). 

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