Methadone at tapered doses for the management of opioid withdrawal

Perceived relapse risk and desire for medication assisted treatment among persons seeking inpatient opiate detoxification

Most patients with opioid addiction do not receive medication at the time of discharge from brief inpatient detoxification programs despite the high risk of relapse and the availability of three FDA-approved medications. We surveyed 164 inpatient opioid detoxification patients to assess desire for pharmacotherapy following detoxification program discharge. Participants were predominantly male (71.3%) and 80% had detoxed in the past. Reporting on their most recent previous inpatient detoxification, 27% had relapsed the day they were discharged, 65% within a month of discharge, and 90% within a year of discharge. 63% reported they wanted medication-assisted treatment (MAT) after discharge from the current admission. The odds of desiring a treatment medication increased by a factor of 1.02 for every 1% increase in perceived relapse risk (p<.01). These data suggest patient preference discussions including relapse risk could increase post-detox abstinence.

Methadone at tapered doses for the management of opioid withdrawal

BACKGROUND

The evidence of tapered methadone's efficacy in managing opioid withdrawal has been systematically evaluated in the previous version of this review that needs to be updated

OBJECTIVES

To evaluate the effectiveness of tapered methadone compared with other detoxification treatments and placebo in managing opioid withdrawal on completion of detoxification and relapse rate.

SEARCH METHODS

We searched: Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 4), PubMed (January 1966 to May 2012), EMBASE (January 1988 to May 2012), CINAHL (2003- December 2007), PsycINFO (January 1985 to December 2004), reference lists of articles.

SELECTION CRITERIA

All randomised controlled trials that focused on the use of tapered methadone versus all other pharmacological detoxification treatments or placebo for the treatment of opiate withdrawal.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the included studies. Any doubts about how to rate the studies were resolved by discussion with a third review author. Study quality was assessed according to the criteria indicated in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Twenty-three trials involving 2467 people were included. Comparing methadone versus any other pharmacological treatment, we observed no clinical difference between the two treatments in terms of completion of treatment, 16 studies 1381 participants, risk ratio (RR) 1.08 (95% confidence interval (CI) 0.97 to 1.21); number of participants abstinent at follow-up, three studies, 386 participants RR 0.98 (95% CI 0.70 to 1.37); degree of discomfort for withdrawal symptoms and adverse events, although it was impossible to pool data for the last two outcomes. These results were confirmed also when we considered the single comparisons: methadone with: adrenergic agonists (11 studies), other opioid agonists (eight studies), anxiolytic (two studies), paiduyangsheng (one study). Comparing methadone with placebo (two studies) more severe withdrawal and more drop-outs were found in the placebo group. The results indicate that the medications used in the included studies are similar in terms of overall effectiveness, although symptoms experienced by participants differed according to the medication used and the program adopted.

AUTHORS' CONCLUSIONS

Data from literature are hardly comparable; programs vary widely with regard to the assessment of outcome measures, impairing the application of meta-analysis. The studies included in this review confirm that slow tapering with temporary substitution of long- acting opioids, can reduce withdrawal severity. Nevertheless, the majority of patients relapsed to heroin use.

Chronic opiate treatment enhances both cocaine-reinforced and cocaine-seeking behaviors following opiate withdrawal

After chronic exposure to psychostimulants or opiates, self-administration or conditioned place preference with either class is increased (sensitized). Cross-sensitization of conditioned place preference, i.e., enhancement of psychostimulant-induced preferences after exposure to opiates, has also been described, but increases in cocaine self-administration after morphine pretreatment have not been reported. The present study evaluated effects of chronic morphine treatment on cocaine reinforcement. Opiate dependence was established in Wistar rats by administration of morphine as a constant infusion that was gradually increased to a dose of 50mg/kg per day over a 1-week period. Immediately after discontinuation of chronic morphine treatment, animals were allowed to acquire cocaine self-administration under a simple fixed-ratio schedule (FR-1), and were subsequently advanced to a progressive ratio schedule. Acquisition of cocaine self-administration under the FR-1 did not differ in saline- and morphine-pretreated animals. For cocaine self-administration under a progressive ratio schedule measured at 5 or more days after the onset of opiate withdrawal, chronic pretreatment with morphine increased the number of ratios completed, augmented final response requirements, and produced a more stable pattern of cocaine self-administration. Responding was also increased in morphine-pretreated animals during an initial extinction session. These results show that chronic opiate treatment can enhance both cocaine-reinforced and cocaine-seeking behaviors following opiate withdrawal. A similar effect may occur in human patients who discontinue methadone or other forms of replacement therapy for opiate abuse, and may contribute to relapse involving use of cocaine or other psychostimulants.

Effectiveness of interventions on opiate withdrawal treatment: an overview of systematic reviews

AIM

To provide an overview of 5 Cochrane reviews of different approaches for treating opioid withdrawal.

DESIGN

Narrative and quantitative summary of review findings.

PARTICIPANTS

There were 46 studies included in the original reviews with a total of 3350 participants (range 18-300).

INTERVENTION

The 5 reviews considered 46 studies covering seven different comparisons, the major ones being methadone compared with alpha2-adrenergic agonists and other opioid agonists, different alpha2-adrenergic agonists compared with each other and to antagonist-induced withdrawal and buprenorphine.

MEASUREMENTS

The outcomes considered were signs and symptoms of withdrawal, retention in treatment, completion rate, relapse rate and side effects.

FINDINGS

Methadone detoxification results in higher retention in treatment, lower relapse rate and fewer side effects when compared with adrenergic agonists. No difference was observed when comparing different adrenergic agonists; buprenorphine appears to have an advantage over adrenergic agonists on withdrawal symptoms and side effects.

CONCLUSIONS

Despite the considerable number of trials that have been carried out on this topic, they are very heterogeneous as far as the comparisons and outcomes considered. This prevented many of them from being incorporated into a quantitative meta-analysis. Consensus in measurements and results should be reached among researchers involved in the evaluation of the effectiveness of treatments for opiate addiction in order to produce consistent outcomes in the measuring and reporting of results from clinical trials.