Methadone alternative

Rx 3X/WEEK LAAM - ALTERNATIVE TO METHADONE. Jack Blaine, M.D.,... 

While there are extensive data on the use of methadone substitution therapy in adult opiate-dependent patients, there are only two published studies on opiate substitution therapy in adolescents and most of these subjects were 18 years of age or older (Hopfer et al., 2000). This lack of research is particularly concerning, given the recent increase in heroin use among adolescents (Hopfer et ah, 2000). Two newer substitution agents, L-oc acetylmethadol (LAAM) and buprenor-phine, offer alternatives to methadone, but remain untested in youth with SUD (Kranzler et al., 1999). 

There are a range of more minor adverse effects, however, which are often not mentioned in formal reviews of methadone treatment but which are discussed more in practical handbooks. In clinical practice these can be very problematic, variously leading to distress for individuals, limitations in compliance and requests for alternative treatments, and the most troublesome such effects are listed in Table 1.4. 

In the course of clinical treatment with methadone, certain situations relating to adverse effects are characteristic. Nausea is a general opiate effect, but complaints most frequently relate to the methadone mixture. This preparation does have a syrupy consistency, but the problem for clinicians is that the alternatives - sugar-free mixture or methadone tablets - are both more injectable, and therefore requests or implied requirements for these are often manipulative. So are requests for the antiemetic cyclizine tablets, which are crushed and injected by drug misusers along with injected methadone. As indicated in Chapter 4, thankfully these particular claims have become less common now that guidelines are much more discouraging of any use of methadone tablets. 

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... 

For those of us in countries where buprenorphine and methadone are absolutely direct alternatives, with very broadly about half of presenting patients choosing one medication and half the other, there are two characteristics of the literature on buprenorphine from other countries which strike unusual notes. For anyone reviewing this area they will soon notice that an exceptional proportion of the literature comes from France (e.g. Auriacombe et al. 1999, Carrier et al. 2006), and this is because even though buprenorphine use in substitution treatment there is recent, as it is everywhere else, methadone had not been... 

Is the main alternative to methadone, used just as much in many areas... 

The profile of buprenorphine has been discussed in Chapter 2, a partial opioid agonist and partial antagonist with several potential advantages as a direct alternative to methadone. The prominence which the medication has reached within treatment, actually in about the time since the first edition of this book, has also been referred to at several points, and as... 

Regarding effectiveness of naltrexone, it has never ceased to amaze me how naltrexone tends to be portrayed in the literature, almost as if it is some kind of direct alternative to methadone in the same indications. If very recently active long-standing opiate addicts are... 

This book is mainly concerned with the treatment of opiate misuse, for the simple reason that that is the form of drug misuse for which there are the most effective clinical approaches. As we have discussed, the treatment scene for opiate misusers, in contrast to other groups, is fundamentally altered by the widespread availability of the substitution option, in the form of methadone or alternative opioids. Physical dependence is part of the rationale for that approach, and the occurrence of clear-cut withdrawal symptoms also indicates the use of drugs such as lofexidine or clonidine, followed where possible by naltrexone. For reasons of severity of dependence and treatment options, it is therefore understandable that services are inclined to have caseloads dominated by opiate users. 

The important difference in the cocaine-abusing opioid patient scenario is that there is also the dose of methadone, buprenorphine or alternative to consider, and there seems little doubt in practice and from study results that at least some individuals will refrain from other drug use better if their opioid is increased (Faggiano et al. 2004). 

Robertson JR, Raab GM, Bruce M, McKenzie JS, Storkey HR Salter A (2006). Addressing the efficacy of dihydrocodeine versus methadone as an alternative maintenance treatment for opiate dependence a randomized controlled trial. Addiction, 101, 1752-9... 

Because BZDs can cause excessive sedation and misuse, especially in drug-abusing HIV-infected patients, buspirone may be a useful alternative. Batki ( 496) reported on the use of this agent in 17 opiate abusers with AIDS or ARC who were also taking methadone. In the 14 patients who remained on the drug for at least 2 weeks, there was a reduction in several aberrant behaviors without any incidence of abuse. 

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