Opioid dependence patients

Tennant FS, Rawson RA, Pumphrey E, et al Clinical experiences with 959 opioid-dependent patients treated with levo-alpha-acetylmethadol (LAAM). J Suhst Abuse Treat 3 195-202, 1986... 

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). 

Studies have shown that CM can be used to directly reinforce adherence to medication treatments as well (Petty 2000). Liebson et al (1978) found that methadone-maintained alcohol-dependent patients reduced alcohol use when methadone treatment was contingent on disulfiram consumption. To date, one of the most common applications of CM techniques to pharmacotherapy has been the provision of vouchers or cash contingent upon naltrexone consumption in recently detoxified opioid-dependent patients (Carroll et al. 2001, 2002 Preston et al. 1999). These studies have generally reported significant increases in retention and reductions in opioid use among patients receiving the CM treatment, relative to other therapies. 

In other substance use disorders, the use of 12-step interventions is also popular, and participation in 12-step groups is correlated with better outcomes in cocaine abusers (e.g., McKay et al. 1994). However, a smdy of 128 cocaine abusers found that cognitive-behavioral therapy was more efficacious than 12-step facilitation in engendering cocaine abstinence (Maude-Griffm et al. 1998). Thus, the relative efficacy of 12-step approaches for drug use disorders requires further investigation. No known studies have systematically evaluated the efficacy of 12-step treatments in opioid-dependent patients, either alone or in conjunction with pharmacotherapies. 

This class produces analgesia and has a ceiling effect on respiratory depression and lower abuse potential than morphine. However, psychotomimetic responses (e.g., hallucinations and dysphoria with pentazocine), a ceiling analgesic effect, and the propensity to initiate withdrawal in opioid-dependent patients have limited their widespread use. 

Patients receiving opioid analgesics opioid-dependent patients patients in acute opioid withdrawal failed naloxone challenge positive urine screen for opioids history of sensitivity to naltrexone acute hepatitis or liver failure. 

Opioid antagonists bind to the opioid receptor with high affinity and have low efficacy. The pure antagonists block the effects of opioids at all opioid receptors. However, as previously discussed, the dose required for naloxone blockade of the jx-receptor versus the k-opioid receptor is several times as much. All opioid antagonists will precipitate withdrawal in opioid-dependent patients. 

Ball SA (2007). Comparing individual therapies for personality disordered opioid dependent patients. Journal of Personality Disorders, 21, 305-21... 

Budney AJ, Bickel WK Amass L (1998). Marijuana use and treatment outcome among opioid-dependent patients. Addiction, 93, 493-503... 

Justo D, Gal-Oz A, Paran Y, Goldin Y Zeltser D (2006). Methadone-associated Torsades de pointes (polymorphic ventricular tachycardia) in opioid-dependent patients. Addiction, 101, 1333-8... 

Mattick RP Hall W (1996). Are detoxification programmes effective. Lancet, 347, 97-100 Mattick RP, Ali R, White JM, O Brien S, Walk S Danz C (2003). Buprenorphine versus methadone maintenance therapy a randomized double-blind trial with 405 opioid-dependent patients. Addiction, 98, 441-52 Mattick RP, Kimber J, Breen C Davoli M (2004). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence (Cochrane Review). The Cochrane Library, issue 2. Chichester, UK John Wiley Sons... 

Musselman DL Kell MJ (1995). Prevalence and improvement in psychopathology in opioid dependent patients participating in methadone maintenance. Journal of Addictive Diseases, 14, 67-82... 

Ferner RE, Daniels AM Office-based treatment of opioid-dependent patients. N Engl J Med 2003 348 81. [PMID ... 

Two patients who were hospitalized with a diagnosis of opioid dependence received concomitant treatment with methadone 50 mg/day in one case, and levorpha-nol 14 mg/day in the other, each in association with risperidone. After several days, both had symptoms of opioid withdrawal despite having no change in their opioid doses (256). The withdrawal symptoms resolved soon after risperidone was withdrawn. According to the authors, this finding suggests that risperidone may precipitate opioid withdrawal in opioid-dependent patients. 

Symptoms of anxiety are common among opioid-depen-dent individuals. Although buspirone has been used successfully for the treatment of anxiety in alcoholic patients, its efficacy in opioid-dependent patients had not been previously examined. In a 12-week, randomized, placebo-controlled trial of buspirone in 36 subjects receiving methadone maintenance treatment who presented with symptoms of anxiety, buspirone did not significantly reduce anxiety symptoms (18). However, buspirone was associated with trends toward reduction in depression scale scores and a slower return to substance use. 

Reports of some abuse by non-opioid dependent patients... 

Petty NM, Bickel WK, Piasecki D, Marsch LA, Badger GJ. Elevated liver ettzyme levels in opioid-dependent patients with hepatitis treated with buprenorphine. Am J Addict 2000 9(3) 265-9. 

Piquet CY, Mallaret MP, Lemoigne AH, Barjhoux CE, Danel VC, Vincent FH. Respiratory depression following administration of intrathecal bupivacaine to an opioid-dependent patient. Ann Pharmacother 1998 32(6) 653-5. 

Stine SM, Southwick SM, Petrakis IL, Kosten TR, Charney DS, Krystal JH. Yohimbine-induced withdrawal and anxiety symptoms in opioid-dependent patients. Biol Psychiatry 2002 51(8) 642-51. 

Croquette-Krokar M, Hammig R, Monnat M, Preisig M, Eap CB (2011) beta-Arrestin2 influences the response to methadone in opioid-dependent patients. 

Typically, opioid dependency is treated initially with detoxification, usually as an inpatient. Except in a few individuals who remain drug free, detoxification is followed by long-term maintenance therapy. In the pasL opioid-dependent patients relied on methadone or levomethadyl acetate, but federal restrictions limited distribution of these drugs to a small number of methadone clinics, which are not only inconvenient, but also expose patients to other drug users, and can stigmatize patients if friends, family, or coworkers are aware of their trips to the clinic. There were limited provisions for take-at-home dosing of methadone or levomethadyl because of concern about the diversion of these drugs to illicit use. 

A. Naioxone. Administer 0.4-2 mg IV repeat at 2- to 3-minute intervals until desired response is achieved. Titrate carefully in opioid-dependent patients (start at 0.05 mg). The dose for children is the same as for adults. 

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