Methadone maintenance

At present in the United States, methadone is the most commonly used drug to treat withdrawal symptoms. Detoxification can be accomplished over a period as long as 6 months in an ambulatory methadone maintenance program or as brief as several days in a hospital setting. The goal in brief detoxification is to make the experience less distressing, but the suppression of all with-... 

Relapse rates after detoxification are very high. Although extension of the withdrawal period for up to 6 months does not appear to improve outcome (Sees et al. 2000), patients who have received methadone maintenance and who have a good therapeutic relationship have more successful outcomes. 

Methadone maintenance was first introduced in 1964 by Dole and Nyswan-der (1965). The basis for use of methadone is that high doses alleviate craving... 

The initial dose of buprenorphine should be given at least 12-24 hours after the last heroin dose, 24 hours after the last methadone dose, or 48 hours after the last LAAM dose (see Table 2-3). The methadone dosage of methadone maintenance patients should be reduced to 30 mg/day before the transfer to buprenorphine is attempted. Ideally patients should show clear evidence of opiate withdrawal before receiving the first dose of buprenorphine, to avoid the risk that buprenorphine will precipitate more severe withdrawal. For the first day, sublingual buprenorphine/naloxone doses of 2/0.5-4/1 mg can be given every 2-4 hours, up to a maximum total dose of 8/2 mg/day. On the... 

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... 

When patients elect detoxification from maintenance, a very gradual reduction of dosage is preferred, with careful monitoring of drug craving and withdrawal symptoms. Three to 6 months is recommended for most elective detoxifications. As many as one-third of methadone maintenance clients have been found to have a marked fear of detoxification (Milby et al. 1986). 

A later study used DSM-III-R criteria to assess 716 opioid abusers seeking methadone maintenance treatment (Brooner et al. 1997). In evaluations conducted 1 month after admission, psychiatric comorbidity was found in 47% of... 

Clinicians have more recently become more aware of elevated rates of posttraumatic stress disorder (PTSD) in both men and women with opioid dependence (Hien et al. 2000). A lifetime prevalence of PTSD of 20% in women and 11% in men was found in one sample of methadone maintenance patients (Villagomez et al. 1995). Patients often deny a PTSD history during initial assessment. They should be reassessed after they have had the opportunity to develop trust in their treating clinicians. 

A 2.5-yeat follow-up study of opioid addicts in methadone maintenance treatment found that prevalence of cocaine use only shghtly declined and that... 

Anxiety disorders are common in the population of opioid-addicted individuals however, treatment studies are lacking. It is uncertain whether the frequency of anxiety disorders contributes to high rates of illicit use of benzodiazepines, which is common in methadone maintenance programs (Ross and Darke 2000). Increased toxicity has been observed when benzodiazepines are co-administered with some opioids (Borron et al. 2002 Caplehorn and Drummer 2002). Although there is an interesting report of clonazepam maintenance treatment for methadone maintenance patients who abuse benzodiazepines, further studies are needed (Bleich et al. 2002). Unfortunately, buspirone, which has low abuse liability, was not effective in an anxiety treatment study in opioid-dependent subjects (McRae et al. 2004). Current clinical practice is to prescribe SSRIs or other antidepressants that have antianxiety actions for these patients. Carefully controlled benzodiazepine prescribing is advocated by some practitioners. 

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Dean AJ, Bell J, Mascord DJ, et al A randomized, controlled trial of fluoxetine in methadone maintenance patients with depressive symptoms. J Affect Disord 72 ... 

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Tennant FS Inadequate plasma concentrations in some high-dose methadone maintenance patients. Am J Psychiatry 144 1349-1350, 1987... 

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