Methadone detoxification treatments

The factors that correlate with treatment success do not clearly apply to success after detoxification from methadone maintenance. Correlates of successful detoxification include 1) less criminal behavior 2) more stable family 3) more stable employment 4) shorter drug history 5) long maintenance with lower dosage and 6) discharge status, with patient and staff consensus as opposed to unilateral discharge from treatment (Dole and Joseph 1978). In one study, addicts were followed an average of 2 years after detoxification (Stim-mel et al. 1977). Although only 28% of the total sample remained abstinent, 83% of those who had fully completed treatment remained abstinent. Another study of 105 patients detoxified after methadone maintenance treatment documented an 82% relapse rate within 12 months (Ball and Ross 1991). These... 

Maany I, Dhopesh V, Arndt lO, et al Increase in desipramine serum levels associated with methadone treatment. Am J Psychiatry 146 1611—1613, 1989 Maas U, Kattner E, Weingart-Jesse B, et al Infrequent neonatal opiate withdrawal following maternal methadone detoxification during pregnancy. J Perinat Med 18 111-118, 1990... 

The methadone taper can also be conducted as an outpatient. In this case, the taper is done very slowly over a period of several months. Adjuvant medications such as acetaminophen are usually not needed for this slow detoxification. This outpatient taper is often best managed by a methadone clinic, the same clinic that provides methadone maintenance treatment. 

A methadone detoxification is more often completed if it is done as an inpatient than as an outpatient (Gossop et al. 1986), but many individuals are reluctant to be admitted, and various other limitations of inpatient treatment were indicated in the Introduction. In attempting to provide the most useful combination of treatments in a community setting, we have no problem with offering methadone detoxification as an option, basically in cases where there are not the features favourable for the quicker methods. However, we do not expect it to proceed in a simple manner, and some of the more important practical management considerations are discussed below. 

In addition to its use as a primary detoxification agent, lofexidine is used by some clinicians as an adjunctive treatment in a methadone detoxification, to help reduce the ongoing symptoms as reduction occurs. This is not the recommended usage, and a controlled study found guanfacine ineffective in this regard (San et al. 1994). 

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). 

Eklund C, Melin L, Hiltunen A Borg S (1994). Detoxification from methadone maintenance treatment in Sweden long-term outcome and effects on quality of life and life situation. The International Journal of the Addictions, 29, 627-45... 

In a case-control study in 106 heroin-dependent individuals undergoing an opioid detoxification program (n = 19) or a methadone maintenance treatment program (n = 87) there were large significant differences in the mean values of some vitamins and minerals between the heroin-dependent individuals and the healthy, non-dependent controls (37). Dependent individuals had higher white cell counts and transaminases and lower erythrocyte counts and cholesterol, albumin, tocopherol, folic acid, sodium, selenium, and copper concentrations. 

The conventional drug therapy for opioid withdrawal has been methadone, a synthetic opiate. Recently, buprenorphine has been approved for opioid withdrawal and will be discussed in detail below. In detoxification treatment, methadone is administered in decreasing doses over a period not exceeding 30 days (short-term detoxification) or 180 days (long-term detoxification). There are many tapering schedules recommended in the literature. Most patients in withdrawal... 

Naltrexone (25 mg initially), a pure narcotic antagonist, is indicated for the treatment of the opioid-free state in formerly opioid-dependent individuals who have undergone a methadone detoxification program. Patients taking naltrexone may not benefit from opioid-containing medicines, such as cough and cold preparations, antidiarrheal preparations, and opioid analgesics. 

Initially, methadone was limited to detoxification treatment or maintenance treatment within US Food and Drug Administration-approved narcotic addiction programs. This restriction was removed in 1976 all physicians with appropriate Drug Enforcement Agency registration now are allowed to prescribe methadone for analgesia. 

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. 

Methadone, a synthetic narcotic, may be used for the relief of pain, but it also is used in the detoxification and maintenance treatment of those addicted to narcotics. Detoxification involves withdrawing the patient from the narcotic while preventing withdrawal symptoms. 

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Seecof R, Tennant FS Subjective perceptions to the intravenous rush of heroin and cocaine in opioid addicts. Am J Drug Alcohol Abuse 12 79—87, 1987 Sees KL, Delucci KL, Masson C, et al Methadone maintenance vs. 180-day psycho-socially enriched detoxification for treatment of opioid dependence a randomized controlled trial. JAMA 283 1303-1310, 2000 Sells SB Treatment effectiveness, in Handbook on Drug Abuse. Edited by Dupont RE, Goldstein A, O Donnell J. Washington, DC, U.S. Government Printing Office, 1979, pp 105-118... 

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