Opioid Detoxification

At present in the United States, methadone is the most commonly used drug to treat withdrawal symptoms. Detoxification can be accomplished over a period as long as 6 months in an ambulatory methadone maintenance program or as brief as several days in a hospital setting. The goal in brief detoxification is to make the experience less distressing, but the suppression of all with- 

Relapse rates after detoxification are very high. Although extension of the withdrawal period for up to 6 months does not appear to improve outcome (Sees et al. 2000), patients who have received methadone maintenance and who have a good therapeutic relationship have more successful outcomes. 

Clonidine alone may not adequately treat insomnia, diarrhea, muscle aches, restlessness, irritability, or other withdrawal symptoms, which may require other medications. For this reason many programs use lower doses of clonidine than outlined in this table, in combination with oral 

Detoxification is more successful when the patient is transitioned from a stable methadone dose with the support of ongoing therapy than when the patient comes directly from the street for detoxification from heroin. Some practitioners believe that detoxification with clonidine can be more rapid than with methadone, at least on an outpatient basis. One important hmitation of clonidine is that, although it suppresses autonomic signs of withdrawal, subject-reported symptoms, such as lethargy, restlessness, insomnia, and craving, are not well relieved (Charney et al. 1981 Jasinski et al. 1985). Anxiety may 

Ultrarapid detoxification employs general anesthesia and opioid antagonists to accomplish withdrawal more quickly (Alvarez and Carmen del Rio 1999 Bell et al. 1999 Brewer et al. 1998 Brewer and Maksoud 1997 Gerra et al. 2000 Kleber 1998 Rabinowitz et al. 1998 SanandArranz 1999 Shreeram et al. 2001 Stephenson 1997 Strang et al. 1997). Its efficacy and safety are being studied. 

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DasheJS, Jackson GL, Olscher DA, etal Opioid detoxification in pregnancy. Obstet Gynecol 92 854-858, 1998... 

O Connor PG, Carroll KM, Shi JM, et al Three methods of opioid detoxification in a primary care setting a randomized trial. Ann Intern Med 127 526-530, 1997 Oppenheimer E, Tobutt C, Taylor C, et al Death and survival in a cohort of heroin addicts from London clinics a 22-year follow-up study Addiction 89 1299—1308, 1994... 

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... 

Azrin NH, Sisson RW, Meyers R, et al Alcoholism treatment by disulfiram and community reinforcement therapy. J Behav Ther Exp Psy 13 105-112, 1982 Bickel WK, Amass L, Higgins ST, et al Effects of adding behavioral treatment to opioid detoxification with buprenorphine. J Consult Clin Psychol 65 803—810, 1997 Bien TH, Miller WR, Tonigan JS Brief interventions for alcohol prohlems a review. Addiction 88 315-335, 1993... 

General Patient Guidelines for Outpatient Opioid Detoxification... 

Methadone is typically used during opioid detoxification in conjunction with acetaminophen, promethazine, and/or clonidine. 

Naloxone is used for rapid opioid detoxification in conjunction with anesthetic agents for conscious sedation. 

Amato L, Minozzi S, Davoli M, Vecchi S, Ferri M, Mayet S. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Syst Rev 2004. 

In defence of methadone, the main difficulties some individuals have are of adjusting first to its (relatively) noneuphoriant effect, and then to the prospect of being without drugs altogether (Milby et al. 1986). Methadone is used for more difficult candidates than non-opioid detoxification, and courses may become protracted partly due to actual reluctance to reduce, which compounds any difficulties relating to the drug. If detoxification has been imposed on an individual who is not ready to do it, the particular withdrawal syndrome of methadone is unlikely to be the critical factor, although it may not help. 

Merrill J Marshall R (1997). Opioid detoxification using naloxone. Drug and Alcohol... 

The concurrent administration of methadone to heroin addicts known to be recidivists has been questioned because of the increased risk of overdose death secondary to respiratory arrest. Buprenorphine, a partial M-receptor agonist with long-acting properties, has been found to be effective in opioid detoxification and maintenance programs and is presumably associated with a lower risk of such overdose fatalities. 

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. 

Daws, L. C. and White, J. M. Regulation of opioid receptors by opioid antagonists implications for rapid opioid detoxification. Addiction Biol. 4 (1999) 391-397. 

In a case-control study in 106 heroin-dependent individuals undergoing an opioid detoxification program (n = 19) or a methadone maintenance treatment program (n = 87) there were large significant differences in the mean values of some vitamins and minerals between the heroin-dependent individuals and the healthy, non-dependent controls (37). Dependent individuals had higher white cell counts and transaminases and lower erythrocyte counts and cholesterol, albumin, tocopherol, folic acid, sodium, selenium, and copper concentrations. 

A widely used technique for opioid detoxification, pioneered by Isbell and Vogel (64), involves the substitution of methadone for the illicit opioid, followed by a gradual reduction in the amount of methadone taken. 

Six cases of complications loosely related to the use of naltrexone pellet implantation during the highly controversial rapid and ultra-rapid opioid detoxification procedures have been reported (22). These included pulmonary edema, prolonged opioid withdrawal states, drug toxicity, withdrawal from cross-dependence to alcohol and benzodiazepines, aspiration pneumonia, and death. The risk of these controversial procedures and of naltrexone in this novel delivery system are high a robust scientifically validated program of research is needed to justify such treatment packages. 

Quigley MA, Boyce SH. Unintentional rapid opioid detoxification. Emerg Med J 2001 18(6) 494-5. 

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. 

RonnsaviUe BJ, Kosten T, Kleber H. Snccess and failure at outpatient opioid detoxification. Evalnating the process of clonidine- and methadone-assisted withdrawal. J Nerv Ment Dis 1985 173(2) 103-10. 

Effects of adding behavioral treatment to opioid detoxification with buprenorphine. Journal of Consulting and Clinical Psychology, 65, 803-810. 

O Connor PG, Kosten TR. Rapid and ultrarapid opioid detoxification techniques. JAMA 1998 279 229-234. 

Methadone is a potent synthetic opioid analgesic, structurally unrelated to any of the opium-derived alkaloids. It is a highly lipophilic, basic drug (pKa 9.2) available as a hydrochloride powder formulation that can be reconstituted for oral, rectal, or parenteral administration. Methadone was developed in Germany in 1942 as a synthetic substitute for morphine, and has been approved and widely employed for opioid detoxification maintenance as well as acute and chronic pain management. 

Cionidine magnesium sulfate ultra-low-dose opioid antagonists ultra-rapid opioid detoxification... 

Drug dependence Buprenorphine is suitable for treating opioid withdrawal. In a systematic review, buprenorphine was associated with low rates of full abstinence from drugs after opioid detoxification, and although detoxification with buprenorphine occurred over a shorter period, this was not associated with shifts in abstinence rates [188 ]. 

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