Naltrexone, detoxification with

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. 

Umbricht A, Hoover DR, Tucker MJ, et al Opioid detoxification with buprenorphine, clonidine, or methadone in hospitalized heroin-dependent patients with HIV infection. Drug Alcohol Depend 69 263-272, 2003 Villagomez RE, Meyer TJ, Lin MM, et al Post-traumatic stress disorder among inner city methadone maintenance patients. Subst Abuse Treat 12 253—257, 1995 Mining E, Kosten TR, Kleber H Clinical utility of rapid clonidine-naltrexone detoxification for opioid abusers. Br J Addict 83 567-575, 1988 Washton AM, Pottash AC, Gold MS Naltrexone in addicted business executives and physicians. J Clin Psychiatry 45 39 1, 1984 Wesson DR Revival of medical maintenance in the treatment of heroin dependence (editorial). JAMA 259 3314-3315, 1988... 

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. 

Jane had unsuccessfuily attempted detoxification with lofexidine about six months previously. At the time she had been keen to have this method and then go on naltrexone, but the main problem had been that she was unable to satisfactorily reduce her heroin use in preparation. She also had the ongoing stresses of child care, although she had had some help offered. 

As mentioned earlier in the chapter, in the UK lofexidine is far more frequently selected in opiate detoxification than clonidine because of its better safety for outpatients, and a large comparative study of this and buprenorphine was carried out by Raistrick et al. (2005). Two hundred and ten patients were randomized, and the same comparisons in standard drug misuse outcomes and satisfaction measures were also studied in 271 individuals who did not wish to be in the randomized study. Many outcomes were similar with the two medications, but 65% of buprenorphine patients completed detoxification against 46% of those on lofexidine. That study was an example of one which included a follow-up to see whether patients had been abstinent after detoxification, with this being the case at the measurement point of one month for 38% of lofexidine completers and 46% with buprenorphine. This important aspect of whether successful detoxification does indeed lead to further abstinence has attracted attention in several buprenorphine studies, as reviewed by Horspool et al. (2008). Across five qualifying studies, they found detoxification completion rates of 65 to 100%, but low rates of abstinence at follow-up points, with more patients having returned to opioid maintenance than had complied with naltrexone. 

Kerry had a one-year history of heroin use before undergoing a straightforward community detoxification with lofexidine and symptomatic medication. She was keen to go on naltrexone, and we supervised the first half-tablet dose, eight days after her last use of heroin. Her mother had helped her through the detoxification at home, and was also going to make sure that Kerry had her naltrexone each day. They were given a patient information leaflet, and a medical warning card for Kerry to carry with her at all times. 

Hamilton RJ, Olmedo RE, Shah S, Hung OL, Howland MA, Perrone J, Nelson LS, Lewin NL, Hoffman RS. Comphcations of ultrarapid opioid detoxification with subcutaneous naltrexone pellets. Acad Emerg Med 2002 9(l) 63-8. 

Rabinowitz J, Cohen H, Kotler M Outcomes of ultrarapid opiate detoxification combined with naltrexone maintenance and counseling. Psychiatr Serv 49 831—833, 1998 Reed PA, Schnoll SH Abuse of pentazocine-naloxone combination. JAMA 256 2562— 2564, 1986... 

Naloxone (Narcan). Naloxone, like naltrexone, is a potent opioid receptor blocker. Its primary use has been to reverse opiate toxicity after an overdose. However, some physicians have found it is also useful for a process known as rapid opiate detoxification. Although opiate withdrawal is not life threatening, it can be extremely unpleasant. Most opiate addicts are fearful of the withdrawal symptoms therefore, it usually requires a slow, deliberate detoxification to keep the withdrawal symptoms in check. Rapid opiate detoxification is an alternative approach that keeps the taper and detoxification as brief as possible. In this approach, naloxone is used in conjunction with general anesthesia or a nonopiate sedative such as the benzodiazepine mid-... 

Less interaction with other euphoriant drugs Sooner transfer to naltrexone after detoxification... 

Lee s progress through the detoxification was uneventful, with poor sleep the most troublesome aspect. He was pleasantly surprised with the low level of withdrawal discomfort, compared to his own attempts to come off heroin without medication. He and his parents followed the instructions carefully, and in all Lee used about three-quarters of the available medication, apart from the sleeping tablets, which were all necessary. Nine days after his last use of heroin naltrexone was instituted, with no withdrawal reaction. 

Buntwal N, Bearn J, Gossop M Strang J (2000). Naltrexone and lofexidine combination treatment compared with conventional lofexidine treatment for in-patient opiate detoxification. Drug and Alcohol Dependence, 59, 183-8... 

Rosen M Kosten TR (1995). Detoxification and induction onto naltrexone. In Cowan A Lewis JW (eds.) Buprenorphine Combatting Drug Abuse with a Unique Opioid. New York Wiley-Liss, pp. 289-305... 

Clonidine (Catapres) is another drug used to treat opiate addiction. It can relieve the anxiety, runny nose, salivation, sweating, abdominal cramps, and muscle aches of opiate withdrawal. Side effects are dry mouth, dizziness, and drowsiness. Clonidine is initially taken at 0.8-1.2 mg a day, maintained for a few days, and then gradually decreased. Combined with the opiate blocker naltrexone, clonidine can allow a more rapid detoxification (the removal of morphine from the body). Detox in a single day can be accomplished by heavy sedation or anesthesia while giving naltrexone to an unconscious addict. This controversial method has not been studied in controlled trials. 

The major limitation to the effective use of naltrexone resides in patient compliance. As stated by Fraser, The major limitation on the use of naltrexone, however, is the lack of incentive for the patient to keep taking the medication. As further stated by Littrel and Hyde, If patients comply with naltrexone treatment after detoxification, opioid discontinuation is usually maintained and craving is ablated. However, the clinical usefulness of naltrexone... 

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