Dependence, drug detoxification after

With drugs that produce a depression after chronic exposure (e.g., alcohol), detoxification is instituted, in addition to supportive care and therapy for substance dependency. Even though most alcoholics will experience depression immediately after the cessation of heavy and prolonged consumption, the majority will remit within several weeks following detoxification and supportive care (see Chapter 14, The Alcoholic Patient ). For those who do not, it is likely there had been a preexisting depressive disorder, which itself can lead to substance dependency, because patients frequently self-medicate before seeking professional intervention. This possibility should be evaluated through a review of the patient s personal medical and psychiatric history, as well as family history. 

After detoxification, psychosocial therapy either in intensive inpatient or in outpatient rehabilitation programs serves as the primary treatment for alcohol dependence. Other psychiatric problems, most commonly depressive or anxiety disorders, often coexist with alcoholism and, if untreated, can contribute to the tendency of detoxified alcoholics to relapse. Treatment for these associated disorders with counseling and drugs can help decrease the rate of relapse for alcoholic patients. 

The time of onset, intensity, and duration of abstinence syndrome depend on the drug previously used and may be related to its biologic half-life. With morphine or heroin, withdrawal signs usually start within 6-10 hours after the last dose. Peak effects are seen at 36-48 hours, after which most of the signs and symptoms gradually subside. By 5 days, most of the effects have disappeared, but some may persist for months. In the case of meperidine, the withdrawal syndrome largely subsides within 24 hours, whereas with methadone several days are required to reach the peak of the abstinence syndrome, and it may last as long as 2 weeks. The slower subsidence of methadone effects is associated with a less intense immediate syndrome, and this is the basis for its use in the detoxification of heroin addicts. However, despite the... 

Methadone is widely used in the treatment of opioid abuse. Tolerance and physical dependence develop more slowly with methadone than with morphine. The withdrawal signs and symptoms occurring after abrupt discontinuance of methadone are milder, although more prolonged, than those of morphine. These properties make methadone a useful drug for detoxification and for maintenance of the chronic relapsing heroin addict. 

In 1951, disulfiram was the first medication approved by the U.S. Food and Drug Administration (FDA) for the treatment of alcohol dependence other than detoxification. Disulfiram inhibits a key enzyme, aldehyde dehydrogenase, involved in breakdown of ethyl alcohol. After drinking, the alcohol-disulfiram reaction produces excess blood levels of acetaldehyde, which is toxic in that it produces facial flushing, tachycardia, hypotension, nausea and vomiting, and physical discomfort. Opioid receptors antagonists, such as naloxone and naltrexone (see Chapter 47) that block opioid receptors have been found to decrease alcohol consumption (Cornish et al 2004). 

Drug dependence Buprenorphine is suitable for treating opioid withdrawal. In a systematic review, buprenorphine was associated with low rates of full abstinence from drugs after opioid detoxification, and although detoxification with buprenorphine occurred over a shorter period, this was not associated with shifts in abstinence rates [188 ]. 

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