0
0

Chapter 14. Pharmacological Treatments for Opioid Addiction

Eric D. Collins, M.D.; Herbert D. Kleber, M.D.; Charles P. O'Brien, M.D., Ph.D.; Kyle M. Kampman, M.D.; Richard S. Schottenfeld, M.D.

Sections

Excerpt

Opioid detoxification continues to be employed by the majority of heroin abusers as a pretreatment procedure prior to drug-free treatments, including opioid antagonist maintenance. Some individuals seek detoxification but do not seek long-term treatment, either because they expect to remain opioid-abstinent without additional help or because they do not seriously intend to remain abstinent. For those patients who do seek additional treatment, the prerequisite detoxification and withdrawal discomfort are often a barrier to entering and/or completing treatment. Thus, while detoxification is a necessary part of treatment for many patients, it has not achieved its full potential for the transition from opioid dependence to drug-free and/or antagonist maintenance treatments. The advent of buprenorphine for opioid detoxification may allow this transition to proceed safely, relatively quickly, and with a minimum of discomfort.

Your session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
 
Username
Password
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Table Reference Number
Table 14A–1. Signs and symptoms of opioid withdrawal
Table Reference Number
Table 14A–2. Duration of effects and first appearance of withdrawal
Table Reference Number
Table 14A–3. Drug relationships for withdrawal
Table Reference Number
Table 14C–1. Medication interactions

References

Amass L, Ling W, Freese TE, et al: Bringing buprenorphine-naloxone detoxification to community treatment providers: the NIDA Clinical Trials Network field experience. Am J Addict 13 (suppl 1):S42–S66, 2004
 
Brewer C, Rezae H, Bailey C: Opioid withdrawal and naltrexone induction in 48–72 hours with minimal dropout, using a modification of the naltrexone-clonidine technique. Br J Psychiatry 153:340–343, 1988
[PubMed]
 
Charney DS, Sternberg DE, Kleber HD, et al: The clinical use of clonidine in abrupt withdrawal from methadone. Effects on blood pressure and specific signs and symptoms. Arch Gen Psychiatry 38:1273–1277, 1981
[PubMed]
 
Charney DS, Heninger GR, Kleber HD: The combined use of clonidine and naltrexone as a rapid, safe, and effective treatment of abrupt withdrawal from methadone. Am J Psychiatry 143:831–837, 1986
[PubMed]
 
Collins ED, Kleber HD, Whittington RA, et al: Anesthesia-assisted vs buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial. JAMA 294:903–913, 2005
[PubMed]
 
Dart RC, Woody GE, Kleber HD: Prescribing methadone as an analgesic. Ann Intern Med 143:620, 2005
[PubMed]
 
Dashe JS, Jackson GL, Olscher DA, et al: Opioid detoxification in pregnancy. Obstet Gynecol 92:854–858, 1998
[PubMed]
 
Favrat B, Zimmermann G, Zullino D, et al: Opioid antagonist detoxification under anaesthesia versus traditional clonidine detoxification combined with an additional week of psychosocial support: a randomised clinical trial. Drug Alcohol Depend 81:109–116, 2006
[PubMed]
 
Fudala PJ, Jaffe JH, Dax EM, et al: Use of buprenorphine in the treatment of opioid addiction, II: physiological and behavioral effects of daily and alternate-day administration and abrupt withdrawal. Clin Pharmacol Ther 47:525–534, 1990
[PubMed]
 
Gold MS, Redmond DE Jr, Kleber HD: Clonidine blocks acute opiate-withdrawal symptoms. Lancet 2(8090):599–602, 1978
[PubMed]
 
Gossop M, Johns A, Green L: Opiate withdrawal: inpatient versus outpatient programmes and preferred versus random assignment to treatment. BMJ (Clin Res Ed) 293:103–104, 1986
[PubMed]
 
Gossop M, Bradley B, Phillips GT, et al: An investigation of withdrawal symptoms shown by opiate addicts during and subsequent to a 21-day inpatient methadone detoxification procedure. Addict Behav 12:1–6, 1987
[PubMed]
 
Hamilton RJ, Olmedo RE, Shah S, et al: Complications of ultrarapid opioid detoxification with subcutaneous naltrexone pellets. Acad Emerg Med 9:63–68, 2002
[PubMed]
 
Jaffe JH, Martin WR: Narcotic analgesics and antagonists, in The Pharmacological Basis of Therapeutics. Edited by Goodman LS, Gilman A. New York, Macmillan, 1975, pp 245–324
 
Jarvis MA, Schnoll SH: Methadone treatment during pregnancy. J Psychoactive Drugs 26:155–161, 1994
[PubMed]
 
Jarvis MA, Wu-Pong S, Kniseley JS, et al: Alterations in methadone metabolism during late pregnancy. J Addict Dis 18:51–61, 1999
[PubMed]
 
Jasinski DR, Johnson RE, Kocher TR, et al: Clonidine in morphine withdrawal. Differential effects on signs and symptoms. Arch Gen Psychiatry 42:1063–1066, 1985
[PubMed]
 
Jasinski DR, Pevnick JS, Griffith JD: Human pharmacology and abuse potential of the analgesic buprenorphine: a potential agent for treating narcotic addiction. Arch Gen Psychiatry 35:501–516, 1978
[PubMed]
 
Johnson RE, Jones HE, Jasinski DR, et al: Buprenorphine treatment of pregnant opioid-dependent women: maternal and neonatal outcomes. Drug Alcohol Depend 63:97–103, 2001
[PubMed]
 
Kleber HD: Outpatient detoxification from opiates. Primary Psychiatry 1:42–52, 1996
 
Kleber HD, Riordan CE, Rounsaville B, et al: Clonidine in outpatient detoxification from methadone maintenance. Arch Gen Psychiatry 42:391–394, 1985
[PubMed]
 
Ling W, Amass L, Shoptaw S, et al: A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network. Addiction 100:1090–1100, 2005
[PubMed]
 
Martin WR, Jasinski DR: Physiological parameters of morphine dependence in man—tolerance, early abstinence, protracted abstinence. J Psychiatr Res 7:9–17, 1969
[PubMed]
 
McGregor C, Ali R, White JM, et al: A comparison of antagonist-precipitated withdrawal under anesthesia to standard inpatient withdrawal as a precursor to maintenance naltrexone treatment in heroin users: outcomes at 6 and 12 months. Drug Alcohol Depend 68:5–14, 2002
[PubMed]
 
Mello NK, Mendelson JH: Buprenorphine suppresses heroin use by heroin addicts. Science 207:657–659, 1980
[PubMed]
 
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
[PubMed]
 
Reynaud M, Petit G, Potard D, et al: Six deaths linked to concomitant use of buprenorphine and benzodiazepines. Addiction 93:1385–1392, 1998
[PubMed]
 
Schindler SD, Eder H, Ortner R, et al: Neonatal outcome following buprenorphine maintenance during conception and throughout pregnancy. Addiction 98:103–110, 2003
[PubMed]
 
Tracqui A, Kintz P, Ludes B: Buprenorphine-related deaths among drug addicts in France: a report on 20 fatalities. J Anal Toxicol 22:430–434, 1998
[PubMed]
 
Arndt IO, Cacciola JS, McLellan AT, et al: A re-evaluation of naltrexone toxicity in recovering opiate addicts, in Problems of Drug Dependence 1985 (NIDA Research Monograph 67; Publ No ADM-86-1448). Edited by Harris LS. Rockville, MD, National Institute on Drug Abuse, 1986, p 525
 
Auriacombe M, Franques P, Tignol J: Deaths attributable to methadone vs buprenorphine in France (letter). JAMA 285:45, 2001
[PubMed]
 
Comer SD, Collins ED, Kleber HD, et al: Depot naltrexone: long-lasting antagonism of the effects of heroin in humans. Psychopharmacology 159:351–360, 2002
[PubMed]
 
Cornish JW, Metzger D, Woody GE, et al: Naltrexone pharmacotherapy for opioid dependent federal probationers. J Subst Abuse Treat 14:529–534, 1997
[PubMed]
 
Croop RS, Faulkner EB, Labriola DF: The safety profile of naltrexone in the treatment of alcoholism: results from a multicenter usage study. The Naltrexone Usage Study Group. Arch Gen Psychiatry 54:1130–1135, 1997
[PubMed]
 
Garbutt JC, Kranzler HR, O'Malley SS, et al: Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA 293:1617–1625, 2005
[PubMed]
 
Kleber HD, Kosten TR, Gaspari J, et al: Nontolerance to the opioid antagonism of naltrexone. Biol Psychiatry 2:66–72, 1985
 
Ling W, Wesson DR: Naltrexone treatment for addicted health-care professionals: a collaborative private practice experience. J Clin Psychiatry 45:46–48, 1984
[PubMed]
 
Marrazzi MA, Wroblewski JM, Kinzie J, et al: High-dose naltrexone and liver function safety. Am J Addict 6:21–29, 1997
[PubMed]
 
O'Brien CP, Greenstein R, Mintz J, et al: Clinical experience with naltrexone. Am J Drug Alcohol Abuse 2:365–377, 1975
[PubMed]
 
Pfohl D, Allen J, Atkinson R, et al: Trexan (naltrexone hydrochloride): a review of hepatic toxicity at high dosage, in Problems of Drug Dependence 1985 (NIDA Research Monograph 67; Publ No ADM-86-1448). Edited by Harris LS. Rockville, MD, National Institute on Drug Abuse, 1986, pp 66–67
 
Roth A, Hogan I, Farren C: Naltrexone plus group therapy for the treatment of opiate-abusing health care professionals. J Subst Abuse Treat 14:19–22, 1997
[PubMed]
 
Sax DS, Kornetsky C, Kim A: Lack of hepatotoxicity with naltrexone treatment. J Clin Pharmacol 34:898–901, 1994
[PubMed]
 
Washton AM, Pottash AC, Gold MS: Naltrexone in addicted business executives and physicians. J Clin Psychiatry 45:39–41, 1984
[PubMed]
 
Amato L, Minozzi S, Davoli M, et al: Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database Syst Rev (4):CD005031, 2004
 
Anglin MD, Speckart GR, Booth MW, et al: Consequences and costs of shutting off methadone. Addict Behav 14:307–326, 1989
[PubMed]
 
Archie C: Methadone in the management of narcotic addiction in pregnancy. Obstet Gynecol 10:435–440, 1998
[PubMed]
 
Avants SK, Margolin A, Kosten TR, et al: When is less treatment better? The role of social anxiety in matching methadone patients to psychosocial treatments. J Consult Clin Psychol 66:924–931, 1998
[PubMed]
 
Ball JC, Ross A: The Effectiveness of Methadone Maintenance Treatment. New York, Springer-Verlag, 1991
 
Compton P, Charuvastra VC, Ling W: Pain intolerance in opioid-maintained former opiate addicts: effect of long-acting maintenance agent. Drug Alcohol Depend 63:139–146, 2001
[PubMed]
 
Darke S, Swift W, Hall W, et al: Drug use, HIV risk-taking and psychosocial correlates of benzodiazepine use among methadone maintenance clients. Drug Alcohol Depend 34:67–70, 1993
 
Donny EC, Walsh SL, Bigelow GE, et al: High-dose methadone produces superior opioid blockade and comparable withdrawal suppression to lower doses in opioid-dependent humans. Psychopharmacology 161:202–212, 2002
[PubMed]
 
Dyer KR, Foster DJ, White JM, et al: Steady-state pharmacokinetics and pharmacodynamics in methadone maintenance patients: comparison of those who do and do not experience withdrawal and concentration-effect relationships. Clin Pharmacol Ther 65:685–694, 1999
[PubMed]
 
Eap CB, Broly F, Mino A, et al: Cytochrome P450 2D6 genotype and methadone steady-state concentrations. J Clin Psychopharmacol 21:229–234, 2001
[PubMed]
 
Fairbank JA, Dunteman GH, Condelli WS: Do methadone patients substitute other drugs for heroin? Predicting substance use at 1-year follow-up. Am J Drug Alcohol Abuse 19:465–474, 1993
[PubMed]
 
Fiellin DA, O'Connor PG, Chawarski M, et al: Methadone maintenance in primary care: a randomized controlled trial. JAMA 286:1724–1731, 2001
[PubMed]
 
Foster DJ, Somogyi AA, Dyer KR, et al: Steady-state pharmacokinetics of (R)- and (S)-methadone in methadone maintenance patients. Br J Clin Pharmacol 50:427–440, 2001
 
Gutstein HB, Akil H: Opioid analgesics, in Goodman and Gilman's The Pharmacological Basis of Therapeutics. Edited by Hardman JG, Limbird LL. New York, McGraw-Hill, 2001, pp 569–619
 
Hser YI, Hoffman V, Grella CE, et al: A 33-year follow-up of narcotics addicts. Arch Gen Psychiatry 58:503–508, 2001
[PubMed]
 
Hubbard RL, Craddock SG, Flynn PM, et al: Overview of 1 year follow-up outcomes in Drug Abuse Treatment Outcome Study (DATOS). Psychol Addict Behav 11:261–278, 1997
 
Krantz MJ, Lewkowiez L, Hays H, et al: Torsade de pointes associated with very-high-dose methadone. Ann Intern Med 137:501–504, 2002
[PubMed]
 
Kreek MJ: Methadone-related opioid agonist pharmacotherapy for heroin addiction: history, recent molecular and neurochemical research and future in mainstream medicine. Ann N Y Acad Sci 909:186–216, 2000
[PubMed]
 
McLellan AT, Arndt IO, Metzger DS, et al: The effects of psychosocial services in substance abuse treatment. JAMA 269:1953–1959, 1993
[PubMed]
 
Metzger DS, Woody GE, McLellan AT, et al: Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. J Acquir Immune Defic Syndr 6:1049–1056, 1993
[PubMed]
 
Murrill CS, Weeks H, Castrucci BC, et al: Age-specific seroprevalence of HIV, hepatitis B virus, and hepatitis C virus infection among injection drug users admitted to drug treatment in 6 US cities. Am J Public Health 92:385–387, 2002
[PubMed]
 
Nunes EV, Quitkin FM, Donovan SJ, et al: Imipramine treatment of opiate-dependent patients with depressive disorders: a placebo-controlled trial. Arch Gen Psychiatry 55:153–160, 1998
[PubMed]
 
Rainey PM: HIV drug interactions: the good, the bad, and the other. Ther Drug Monit 24:26–31, 2002
[PubMed]
 
Schottenfeld RS, Chawarski MC, Pakes JR, et al: Methadone versus buprenorphine with contingency management or performance feedback for cocaine and opioid dependence. Am J Psychiatry 162:340–349, 2005
[PubMed]
 
Sees KL, Delucchi KL, Masson C, et al: Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: a randomized controlled trial. JAMA 283:1303–1310, 2000
[PubMed]
 
Strain EC, Bigelow GE, Liebson IA, et al: Moderate- vs high-dose methadone in the treatment of opioid dependence: a randomized trial [see comments]. JAMA 281:1000–1005, 1999
[PubMed]
 
Wines JD Jr, Weiss RD: Opioid withdrawal during risperidone treatment. J Clin Psychopharmacol 19:265–267, 1999
[PubMed]
 
Wolff K: Characterization of methadone overdose: clinical considerations and the scientific evidence. Ther Drug Monit 24:457–470, 2002
[PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Related Content
Articles
Books
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 18.  >
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 19.  >
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 20.  >
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 21.  >
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 22.  >
Topic Collections
Psychiatric News
PubMed Articles
Pharmacological therapies for maintenance treatments of opium dependence. Cochrane Database Syst Rev 2013;1():CD007775.doi:10.1002/14651858.CD007775.pub2.
 
  • Print
  • PDF
  • E-mail
  • Chapter Alerts
  • Get Citation