Opioid dependence

The Patient Receiving a Narcotic Antagonist for Treatment of Opioid Dependency... 

Opioidergic agents. Naltrexone and nalmefene, opioid antagonists with no intrinsic agonist properties, have been studied for the treatment of alcohol dependence. Naltrexone has been studied much more extensively than nalmefene for this indication. In 1984 naltrexone was approved by the FDA for the treatment of opioid dependence, and in 1994 it was approved for the treatment of alcohol dependence. Nalmefene is approved in the United States as a parenteral formulation for the acute reversal of opioid effects (e.g., after opioid overdose or analgesia). 

Opioid dependence rarely results ftom the prescribing of opioids temporarily for treatment of acute pain or pain of terminal illness. Even use in chronic... 

Multiple factors interact in complex ways to result in opioid dependence. It is difficult to delineate, even for a specific individual, the precise etiology of dependence. In addition, each of the etiologic factors discussed in this section may play variable roles in initiation of use, maintenance of use, relapse, and recovery. Keeping in mind all of these potential factors is essential when formulating a treatment plan for each individual. 

Psychosocial and environmental factors play a major role in the development and recovery from opioid dependence however, a detailed discussion is beyond the scope of this chapter. In general, the use of such drugs as marijuana and alcohol precedes the use of opioids (Clayton and Voss 1981 Kandel and Faust 1975). Although one cannot predict definitively which users will proceed to opioid use, those who do generally have low self-esteem, disrupted families, and/or difficult relationships with their parents. The increased availability of opioids in inner cities of major urban centers contributes to initiation of use and relapse. It is particularly difficult to avoid use and relapse in areas with high unemployment, poor school systems, and high crime rates, because living in such an area may contribute to the very affects opioid use temporarily reheves. 

The approval of buprenorphine for the office-based treatment of opioid dependence represents a major departure from the earlier methadone clinic system. Physicians with addiction specialist credentials or those who have completed 8 hours of approved training can become qualified to treat up to 30 patients in their private offices. Stable patients may be given prescriptions for up to a month of medication. The combination buprenorphine/naloxone tablet is expected to have minimal risk for diversion. When taken subhnguaUy, as prescribed, naloxone has minimal biologic activity and does not interfere with the buprenorphine dose. However, if an attempt is made to inject the drug, the addict will experience the full antagonist effect of the naloxone. 

Comparable findings for lifetime prevalence of psychiatric disorders were obtained in another study of 133 persons, which also found that 47% received a concurrent DSM-III diagnosis of substance abuse or dependence (Khantzian and Treece 1985). The most frequently abused substances were sedative-hypnotics (23%), alcohol (14%), and cannabis (13%). Similar rates of psychiatric disorders were found in other studies of drug abusers (Mirin et al. 1986 Woody et al. 1983). Although such diagnoses do not imply causality, and, in many cases, opioid dependence causes or exacerbates psychiatric problems, some causal link seems likely (Regier et al. 1990). 

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. 

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. 

Schizophrenia is seen in less than 1% of those treated for opioid dependence (Rounsaville et al. 1982). Opioids appear to have antidopaminergic effects... 

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Lejoyeux et al. 1998). Similar to opioid-dependent persons, these patients reported that they use benzodiazepines to self-medicate anxiety, insomnia, and alcohol withdrawal and, less commonly, to enhance the effects of ethanol. Approximately l6%-25% of patients presenting for treatment of anxiety disorders abuse alcohol (Kushner et al. 1990 Otto et al. 1992). Controversy exists concerning appropriate benzodiazepine prescribing in this population (Cir-aulo and Nace 2000 Posternak and Mueller 2001). 

Partial agonists are in early developmental stages. Agonist replacement is an attractive strategy, because of the successs of methadone and buprenorphine in opioid dependence. 

A meta-analysis of placebo-controlled studies by Levin and Lehman (1991) showed that desipramine produced greater cocaine abstinence than placebo. Although a more recent review did not concur (Lima et al. 2001), secondary analyses of studies with imipramine, desipramine, and bupropion suggested that depressed cocaine abusers are more likely to show significant reductions in cocaine abuse than nondepressed cocaine abusers (Margolin et al. 1995 Nunes et al. 1991 Ziedonis and Kosten 1991). Furthermore, recent work with desipramine supported its efficacy in opioid-dependent patients, particularly in combination with contingency management therapies (Kosten et al. 2004 Oliveto et al. 1999). 

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