Opioid addiction, treatments maintenance treatment

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. 

Administration (FDA) for the treatment of opioid addiction. Treatment is initiated with buprenorphine alone administered sublingually, followed by maintenance therapy with a combination of buprenorphine and naloxone (Suboxone) to minimize abuse potential. The partial agonist properties of buprenorphine limit its usefulness for the treatment of addicts who require high maintenance doses of opioids. However, conversion to maintenance treatment with higher doses of methadone, a full agonist, is possible. 

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... 

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The opioid antagonists naloxone and naltrexone bind to aU three opioid receptors, p, K, and 8. These compounds are antagonists due to their inability to elicit downstream effects of these receptors once bound (Sarton et al. 2008 Yaksh and Rudy 1977). Interestingly, both antagonists have a high binding affinity for MORs. Naloxone is used to reverse the effects of an acute opioid overdose because of its rapid onset of action. Naltrexone elicits similar actions, but has a longer onset and duration of action and hence, is used for the maintenance of treatment for opioid addicts. 

Esteban J, Gimeno C, Barril J, Aragones A, Climent JM and de la Cruz-Pellin M (2003). Survival study of opioid addicts in relation to its adherence to methadone maintenance treatment. Drug and Alcohol Dependence, 70, 193-200. 

There are two main hypotheses about the involvement of endogenous opioid systems in the maintenance of self-injurious behaviors (Sandman, 1988 Buitelaar, 1993). The pain hypothesis suggests that in some subjects self-injury does not induce pain because excessive basal activity of opioid systems in the CNS has led to an opioid analgesic state. The addiction hypothesis posits that particularly repetitive and stereotyped forms of self-injury stimulate the production and release of en-dogeneous opioids. Therefore, chronic maintenance of self-injury may be due to addiction to endogenous opioids or to positive reinforcement by a central release of opioids triggered by the self-injurious behavior. Irrespective of which hypothesis one favors, treatment with opiate antagonists seems to be a rational approach. 

It was the threat of widespread transmission of HIV that led to national policy recommendations for more maintenance opioid substitution treatment to be used in the UK, as part of a package of harm-reduction measures. Two decades on there appears little doubt that the overall approach in this country was successful in limiting HIV rates in injecting addicts (Farrell et al. 2005), although with voluntary testing the true prevalence is unknown, and may possibly be rising at the present time. The resources provided at the time of the... 

Darke S (1998). The effectiveness of methadone maintenance treatment. 3 Moderators of treatment outcome. In Ward J, Mattick RP, Hall W (eds.) Methadone Maintenance Treatment and Other Opioid Replacement Therapies. London Harwood, pp. 75-90 Darke S, Hall W, Wodak A, Heather N Ward J (1992a). Development and validation of a multi-dimensional instrument for assessing outcome of treatment among opiate users the Opiate Treatment Index. British Journal of Addiction, 87, 733-42 Darke S, Hall W, Ross MW Wodak A (1992b). Benzodiazepine use and HIV risk-taking... 

Miotto K, McCann M, Basch J, Rawson R ling W (2002). Naltrexone and dysphoria fact or myth American Journal of Addictions, 11, 151-60 Mitchell TB, White JM, Somogyi AA Bodmer F (2003). Comparative pharmacodynamics and pharmacokinetics of methadone and slow-release oral morphine for maintenance treatment of opioid dependence. Drug and Alcohol Dependence, 11, 85-94 Mitchell TB, White JM, Somogyi AA Bochner F (2004). Slow-release oral morphine versus methadone a crossover comparison of patient outcomes and acceptability as maintenance pharmacotherapies for opioid dependence. Addiction, 99, 940-5 Mitka M (2003). Office-based primary care physicians called on to treat the new addict. Journal of the American Medical Association, 290, 735-6... 

Efficacy and clinical use Naltrexone (Crabtree, 1984 Gonzalez and Brogden, 1988) is a pure opioid antagonist and has no analgesic activity. It is used for the treatment of opioid adverse effects, for opioid detoxification and as maintenance treatment for former addicts to avoid a relapse. In chronic opioid users, naltrexone may precipitate an acute withdrawal reaction. 

Buprenorphine Opioid Buprenorphine is a synthetic p-opioid partial agonist synthesized in 1967 [229] and initially utilized as an analgesic [230]. It was not used as a maintenance treatment for opioid addiction until the mid-1980s. Studies have showed that buprenorphine s effects were longer-acting and that it had a lower potential for abuse than did morphine [231]. Suboxone is a combination of buprenorphine plus naloxone formulated to prevent misuse. 

Pain-relieving action is not superior to that of codeine Response to naloxone in overdose may be unreliable This drug, which does not activate opioid receptors, has been proposed as a maintenance drug in treatment programs for opioid addicts a single oral dose will block the effects of injected heroin for up to 48 hours (A) Amphetamine Buprenorphine Naloxone Naltrexone Propoxyphene... 

Seven opioid addicts, without chronic alcoholism or liver disease, and who were receiving methadone maintenance treatment (45 to 65 mg daily) had an increase in the urinary excretion of the major pyrrolidine metabolite of methadone (an indicator of increased A-demethylation) when given disulfiram 500 mg daily for 7 days. However, there was no effect on the degree of opioid intoxication, nor were withdrawal symptoms experienced. No special precautions would seem to be necessary if both drugs are given. 

Wolstein J, Gastpar M, Finkbeiner T, Heinrich C, Heitkamp R, Poehlke T, Scherbaum N. A randomized, open-label trial comparing methadone and Levo-alpha-acetylmethadol (LAAM) in maintenance treatment of opioid addiction. Pharmacopsychiatry 2009 42 1-8. 

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