Opiates treatment options

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. 

Over the years, antidepressant drugs have become an important treatment option in chronic pain states, in their own right and as adjuncts to opiate treatment. In fact, tricyclic antidepressants are the mainstay of treatment of neuropathic pain conditions such as polyneuropathy, diabetic neuropathy, postherpetic neuralgia and peripheral nerve injury (Sindrup, 1997 Sindrup and Jensen, 1999). Other chronic pain states responsive to antidepressants include osteo- and rheumatoid arthritis, fibromyalgia, and chronic tension headache. 

Treatment programs are also needed to address the concerns of opiate users in developing countries. For example, some Afghan refugee camps have found a need to treat refugees for opium addiction. These refugees include laborers and those dealing with the pain of war wounds. In such situations, treatment options may include alternative medication and education. 

Opioids (heroin) are frequently used in combination with cocaine (speedball) by persons generally involved in crime. Early death may occur as a result of their use. Heroin addicts acquire bacterial infections producing skin abscesses, pulmonary infections, endocarditis, viral hepatitis, and acquired immunodeficiency syndrome (AIDS). There is a range of treatment options for heroin addiction, including medication and behavioral therapies. Methadone, a synthetic opiate medication, blocks the effects of heroin its results are encouraging. 

Additional options for refractory disorders include the augmentation of antidepressant treatment with an opiate blocking agent such as naltrexone or consideration of partial or full hospitalization to provide a more structured environment for normalizing the aberrant eating behavior. 

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). 

It is known, however, that drugs are readily available in many prisons, and the rate of adverse incidents and the time and effort spent in detecting smuggling of drugs in has been enough to persuade some authorities that at least the basics of treatment should be available. The most routine option has become to provide a detoxification for opiate misusers, with for instance lofexidine or dihydrocodeine, and also benzodiazepines will often be issued if there is a history of abuse of these and it is intended to avoid the possibility of fits with a short withdrawal course. The adverse incidents in custody and prisons have included some deaths in users of crack cocaine, with physical explanations postulated but no very satisfactory treatment for cocaine withdrawal indicated. Prison services have typically been wary of methadone, and in favouring lofexidine use it was encouraging that a randomized double-blind trial carried out by prison specialists found lofexidine to be as effective as methadone in relief of withdrawal symptoms (Howells et al. 2002). 

Some experts recommend a newer option for withdrawal known as rapid opiate detoxification (ROD). This method is typically carried out in a hospital or private treatment facility, and as its name implies, it is faster than some of the more conventional methods. In some cases, withdrawal treatment with ROD can be completed in just a few days. Compared with conventional withdrawal treatment, ROD also has been found to cause less physical discomfort. Even more recently, some researchers have investigated an even faster method called ultra-rapid opiate detoxification (UROD), in which the patient goes through withdrawal while asleep under anesthesia. The entire process takes four to seven hours. 

The other pharmacotherapies for opioid dependence listed in Table 15.5 also have fared well in clinical trials. LAAM s eftectiveness convinced the FDA in 1993 to approve it as a treatment for heroin dependence. Buprenorphine also has been shown to be effective in several clinical trials with heroin addicts (Litten Allen, 1999). Therefore, the data show that the clinician has the option of prescribing three opiate agonist or partial agonist drugs in the treatment of opioid dependence, according to the clinician s or the client s preferences. 

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