Episodes of heroin use during maintenance treatment with stable dosage of (-)-alpha-acetylmethadol (methadyl acetate, LAAM)

Stress and opioid use disorder: A systematic review

Medication assisted treatment (MAT) is highly effective in reducing illicit opioid use and preventing overdose in individuals with opioid use disorder (OUD); however, treatment retention of patients engaged in MAT is a significant clinical concern. The experience of stress may contribute to a decision to drop out of treatment. The current study is a systematic review conducted across multiple databases of empirical studies on primary appraisal of stress and its relationship to opioid craving, opioid use, and OUD treatment outcomes. Primary appraisal of stress is defined as an explicit inquiry into individual perception of feeling stressed using a self-report measure administered in laboratory, clinical, or naturalistic environment. A total of 21 included studies were organized into three categories: observed stress, experimentally-induced stress, and stress-focused interventions. Appraised stress was generally associated with greater craving, but associations with opioid use and treatment retention were mixed. All but one study included MAT samples and every study sample included some form of drug counseling. These findings suggest that individuals experience considerable stress in spite of receiving standard treatment for OUD. Psychopharmacological interventions targeting stress were promising, but no behavioral interventions specific to stress management were found. The preliminary results with clonidine and lofexidine targeting stress in individuals with OUD warrant further studies. To better understand the impact of stress in OUD, future research should consider using repeated assessment of stress in the context of daily life. Utilization of behavioral treatments specifically targeting stress could have benefits in improving OUD outcomes.

Substitution pharmacotherapies for opioid addiction: from methadone to LAAM and buprenorphine

The efficacy and cost-effectiveness of opioid substitution therapy for the treatment of opioid addiction has been well documented within the methadone maintenance model for over thirty years. However, methadone does not meet the specific treatment needs of all opioid-dependent persons who might benefit from substitution therapy; consequently, a significant proportion of heroin addicts remain untreated. The recent approval of l-alpha-acetylmethadol (LAAM) as a maintenance treatment agent represents the first opioid substitution alternative to methadone. LAAM is a fundamentally different medication than methadone, with unique pharmacological characteristics. Its use requires a different approach to the clinical management of opioid substitution therapy and a different medication delivery strategy. The availability of LAAM has potential important implications for patients, clinics, and the community at large. Full realization of its advantages could move opioid substitution therapy into mainstream medical care and draw into treatment a substantial number of new patients able to benefit from such treatment. Buprenorphine, the other new opioid substitution therapy under development, shares some common advantages with LAAM. Its high safety profile and low physical dependence liability make it uniquely suitable for a subset of addicts as well as an initial treatment of choice in the opioid substitution treatment armamentarium.

The stability of neuropsychological test performance in a group of parenteral drug users

The stability of neuropsychological performance in a sample of drug abusers was investigated for a wide range of neuropsychological tests, using a test-retest paradigm with 16 parenteral drug users. The battery administered included tests of general intellectual function, abstract reasoning, verbal memory, language, attention, visuospatial ability, set switching, speeded performance, and manipulative dexterity. Stability coefficients were of a moderate to high magnitude for most of the tests and were comparable to coefficients found in other studies of non-drug-users. Two exceptions, however, were the Selective Reminding Test and the Perdue Pegboard. Possible reasons for instability with these two tests are discussed. It is concluded that neuropsychological investigations of drug abusers can yield consistent and reliable data, although further studies should employ alternative and/or supplementary measures of verbal memory and motor function.

Environmental influences on relapse in substance use disorders

Characteristics of the posttreatment environment have been implicated in relapse and recovery in substance use disorders. We summarize these findings and describe how different models of relapse interpret the data and diverge in their representations and measurement operations of environmental variables. The advantages and limitations of common measures of the posttreatment environment are discussed using research on life events and relapse as an example. An alternative approach to representing covariation over time between environmental characteristics and substance use that is derived from an application of behavioral theories of choice to relapse is presented.