Detoxification relapse prevention

Treatment of drug addicts can be sqDarated into two phases detoxification and relapse prevention. Detoxification programs and treatment of physical withdrawal symptoms, respectively, is clinically routine for most drugs of abuse. However, pharmacological intervention programs for relapse prevention are still not veiy efficient. 

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. 

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. 

An important initial intervention for a minority of alcohol-dependent patients is the management of alcohol withdrawal through detoxification. The objectives in treating alcohol withdrawal are relief of discomfort, prevention or treatment of complications, and preparation for rehabilitation. Successful management of the alcohol withdrawal syndrome is generally necessary for subsequent efforts at rehabilitation to be successful treatment of withdrawal alone is usually not sufficient, because relapse occurs commonly. 

Disulfiram An inhibitor of hepatic aldehyde dehydrogenase that converts acetaldehyde (a metabolite of alcohol) into acetic acid. It is used to prevent relapse following alcohol detoxification. 

In the event of relapse, patients often cycle through the detoxification (depending on the duration and intensity of the relapse) and rehabilitation phases of treatment. However, they should be advised that a relapse does not necessarily mean they are starting over and they need not feel too disheartened. Instead, a relapse can be viewed as a learning experience. The circumstances that led to the relapse can be reviewed, identified, and utilized for the development of better strategies to prevent subsequent relapses. 

Historically, the treatment of alcohol use disorders with medication has focused on the management of withdrawal from the alcohol. In recent years, medication has also been used in an attempt to prevent relapse in alcohol-dependent patients. The treatment of alcohol withdrawal, known as detoxification, by definition uses replacement medications that, like alcohol, act on the GABA receptor. These medications (i.e., barbiturates and benzodiazepines) are cross-tolerant with alcohol and therefore are useful for detoxification. By contrast, a wide variety of theoretical approaches have been used to reduce the likelihood of relapse. This includes aversion therapy and anticraving therapies using reward substitutes and interference approaches. Finally, medications to treat comorbid psychiatric illness, in particular, depression, have also been used in attempts to reduce the likelihood of relapse. 

Several other classes of medications have been tried in this disorder. Examples are amantadine, a dopaminergic drug that has been reported to aid in detoxification, fluoxetine, a selective serotonin reuptake antagonist that has been reported to reduce cocaine use, and buprenorphine, a partial opioid agonist that has been found to reduce cocaine self-administration in monkeys. Thus far, all of the studies of medications to help prevent relapse to cocaine dependence have revealed modest benefits at best. Reports of success in uncontrolled trials have not been replicated in carefully controlled, double-blind studies. At present, there is general agreement that no medication is yet available that can be used reliably in the treatment of cocaine addiction. 

EN 1639A UM 792 Nalorex " Trexan ) is one of the phenanthrene series and an analogue of oxymorphone and thebaine, and is also an analogue of the antagonist naloxone. It is a (largely subtype-unselective) opioid RECEPTOR antagonist, and is used orally in detoxification treatment for formerly opioid-dependent individuals to help prevent relapse. 

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