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Stuart Bradley E, Liss D, Pepper Carreiro S, Brush DE, Babu K. Potential uses of naltrexone in emergency department patients with opioid use disorder. Clin Toxicol (Phila) 2019; 57:753-759. [PMID: 30831039 PMCID: PMC6908461 DOI: 10.1080/15563650.2019.1583342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 10/27/2022]
Abstract
Introduction: Despite widespread recognition of the opioid crisis, opioid overdose remains a common reason for Emergency Department (ED) utilization. Treatment for these patients after stabilization often involves the provision of information for outpatient treatment options. Ideally, an ED visit for overdose would present an opportunity to start treatment for opioid use disorder (OUD) immediately. Although widely recognized as effective, opioid agonist therapy with methadone and buprenorphine commonly referred to as "medication-assisted therapy" but more correctly as "medication for addiction treatment" (MAT), can be difficult to access even for motivated individuals due to shortages of prescribers and treatment programs. Moreover, opioid agonist therapy may not be appropriate for all patients, as many patients who present after overdose are not opioid dependent. More treatment options are required to successfully match patients with diverse needs to an optimal treatment plan in order to avoid relapse. Naltrexone, a long-acting opioid antagonist, available orally and as a monthly extended-release intramuscular injection, may represent another treatment option. Methods: We conducted a literature search of MEDLINE and PubMed. We aimed to capture references related to naltrexone and is use as MAT for OUD, as well as manuscripts that discussed naltrexone in comparison toother agents used for MAT, opioid detoxification, and naltrexone metabolism. Our initial search logic returned a total of 618 articles. Following individual evaluation for relevance, we selected 65 for in-depthreview. Manuscripts meeting criteria were examined for citations meriting further review, leading to the addition of 30 manuscripts Conclusions: Here, we review the pharmacology of naltrexone as it relates to OUD, its history of use, and highlight recent studies and new approaches for use of the drug as MAT including its potential initiation after ED visit for opioid overdose.
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Affiliation(s)
- Evan Stuart Bradley
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - David Liss
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephanie Pepper Carreiro
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - David Eric Brush
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - Kavita Babu
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
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Bienek N, Maier C, Kaisler M, Michel-Lauter B, Schwarzer A, Meyer-Frießem CH. Intensity of Withdrawal Symptoms During Opioid Taper in Patients with Chronic Pain—Individualized or Fixed Starting Dosage? PAIN MEDICINE 2019; 20:2438-2449. [DOI: 10.1093/pm/pny320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AbstractObjectiveControlled opioid withdrawal is recommended for patients with chronic noncancer pain (CNCP) with insufficient pain reduction or intolerable side effects while on opioid treatment. Few studies have investigated the management of opioid withdrawal (OW). Most common are protocols with an individualized starting dosage (ISD), calculated from the last opioid intake. After two cases of overdose, we introduced a novel withdrawal protocol using a low fixed starting dosage (FSD) for safety reasons. The present study compares the intensity of withdrawal symptoms using the Subjective Opioid Withdrawal Scale (SOWS) and incidences of serious adverse events (SAE) and dropouts in each taper schedule in 195 CNCP patients with OW in an inpatient facility.MethodsTwo protocols were compared: FSD (2014–2016): N = 68, starting dose: 90 mg morphine/d; and ISD (2010–2014): N = 127, starting dose: 70% of the patient’s daily morphine equivalent dose (MED). Outcome criteria: primary: mean daily SOWS score during the first 10 days (16 questions, daily score 0–64); secondary: change in pain intensity on a numeric rating scale (0–10), rate of dropouts and SAEs. Statistics: Student test, Mann-Whitney U test, chi-square test, analysis of variance, P < 0.05.ResultsThe mean daily SOWS score was lower in the FSD group (14.9 ± 9.4 vs 16.1 ± 10, P < 0.05) due to a lower rate of high-intensity withdrawal symptoms (12.4% vs 17.6%, P < 0.01), particularly in patients on >180 mg MED (9.7% vs 18.4%, P < 0.01). Pain intensity decreased after withdrawal, and the incidence of SAEs and dropouts was low in both groups.ConclusionsThe FSD protocol provides a lesser burden of withdrawal symptoms and equal patient safety. It can be recommended for OW in CNCP patients.
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Affiliation(s)
- Natalia Bienek
- Department of Pain Medicine, Ruhr-University Bochum
- Department of Anaesthesiology and Intensive Care, Klinikum Dortmund, Dortmund, Germany
| | | | | | | | | | - Christine H Meyer-Frießem
- Department of Pain Medicine, Ruhr-University Bochum
- Department of Anaesthesiology, Intensive Care Medicine, Palliative Care Medicine and Pain Management, Medical Faculty of Ruhr-University Bochum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH Bochum, Bochum, Germany
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Digiusto E, Shakeshaft AP, Ritter A, Mattick RP, White J, Lintzeris N, Bell J, Saunders JB. Effects of Pharmacotherapies for Opioid Dependence on Participants' Criminal Behaviour and Expenditure on Illicit Drugs: An Australian National Evaluation (NEPOD). ACTA ACUST UNITED AC 2016. [DOI: 10.1375/acri.39.2.171] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Erol Digiusto
- National Centre in HIV Social Research, University of New South Wales, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
| | | | - Alison Ritter
- Turning Point Alcohol and Drug Centre Inc., Melbourne,Victoria, Australia
| | - Richard P. Mattick
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
| | - Jason White
- Drug and Alcohol Services Council of South Australia, Parkside, South Australia, Australia
| | - Nicholas Lintzeris
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
- National Addiction Centre, Institute of Psychiatry, Kings College, London, United Kingdom
| | - James Bell
- The Langton Centre, Surry Hills, New South Wales, Australia
| | - John B. Saunders
- Mental Health Centre, Royal Brisbane Hospital, Herston, Queensland,Australia
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Blum JM, Biel SS, Hilliard PE, Jutkiewicz EM. Preoperative ultra-rapid opiate detoxification for the treatment of post-operative surgical pain. Med Hypotheses 2015; 84:529-31. [DOI: 10.1016/j.mehy.2015.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 02/16/2015] [Indexed: 02/08/2023]
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Diaper AM, Law FD, Melichar JK. Pharmacological strategies for detoxification. Br J Clin Pharmacol 2014; 77:302-14. [PMID: 24118014 PMCID: PMC4014033 DOI: 10.1111/bcp.12245] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 09/24/2013] [Indexed: 02/06/2023] Open
Abstract
Detoxification refers to the safe discontinuation from a substance of dependence and is distinct from relapse prevention. Detoxification usually takes between a few days and a few weeks to complete, depending on the substance being misused, the severity of dependence and the support available to the user. Psychosocial therapies alongside pharmacological treatments are essential to improve outcome. The dependencies considered in this overview are detoxification from opioids (with methadone, buprenorphine, α2-adrenoceptor agonists and adjunct medications), alcohol (with benzodiazepines, anti-glutamatergics and γ-aminobutyric acid (GABA)-ergic drugs), stimulants and cannabis (with no clear recommended pharmacological treatments), benzodiazepines (with dose tapering) and nicotine (with nicotine replacement therapy, antidepressants and partial agonists). Evidence is limited by a lack of controlled trials robust enough for review bodies, and more research is required into optimal treatment doses and regimes, alone and in combination.
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Brewer C, de Jong C, Williams J. Rapid opiate detoxification and antagonist induction under general anaesthesia or intravenous sedation is humane, sometimes essential and should always be an option. Three illustrative case reports involving diabetes and epilepsy and a review of the literature. J Psychopharmacol 2014; 28:67-75. [PMID: 24043724 DOI: 10.1177/0269881113504835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
When abstinence is an appropriate goal, controlled studies and systematic reviews confirm that rapid, antagonist-precipitated opiate withdrawal procedures are the most effective and cost effective methods of initiating abstinence, and naltrexone (NTX) maintenance. While 'rapid' withdrawal, better conceptualised as Rapid Antagonist Induction (RAI), can often be humanely achieved with modest sedation levels, we present three case histories to support our argument that for some patients, general anaesthesia (GA), or techniques of intravenous sedation (IVS) that approach GA, are essential for safety and success. This includes patients with intercurrent disease (e.g. epilepsy or insulin-dependent diabetes) but also those with severe withdrawal phobia after previous distressing experiences. We discuss the history of the procedure. The dangers of RAI under GA or IVS in experienced hands have been exaggerated and the appropriate expertise should be more easily available. Patients and clinicians readily accept risks of major surgery for the excessive intake of food that causes most obesity. Similar risk-acceptance exists in cosmetic surgery and obstetrics. The increasing use and effectiveness of long-acting implants or depot-injections of NTX for relapse-prevention have largely solved compliance problems that undermined the potential of oral NTX. Their ability to prevent opiate overdose in abstinent, non-tolerant patients also strengthens arguments both for offering RAI as a therapeutic option and for reducing psychological, professional and practical barriers to using it.
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Alexander A, Ajazuddin, Khan J, Saraf S, Saraf S. Poly(ethylene glycol)-poly(lactic-co-glycolic acid) based thermosensitive injectable hydrogels for biomedical applications. J Control Release 2013; 172:715-29. [PMID: 24144918 DOI: 10.1016/j.jconrel.2013.10.006] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 10/02/2013] [Accepted: 10/04/2013] [Indexed: 01/17/2023]
Abstract
Stimuli triggered polymers provide a variety of applications related with the biomedical fields. Among various stimuli triggered mechanisms, thermoresponsive mechanisms have been extensively investigated, as they are relatively more convenient and effective stimuli for biomedical applications. In a contemporary approach for achieving the sustained action of proteins, peptides and bioactives, injectable depots and implants have always remained the thrust areas of research. In the same series, Poloxamer based thermogelling copolymers have their own limitations regarding biodegradability. Thus, there is a need to have an alternative biomaterial for the formulation of injectable hydrogel, which must remain biocompatible along with safety and efficacy. In the same context, poly(ethylene glycol) (PEG) based copolymers play a crucial role as a biomedical material for biomedical applications, because of their biocompatibility, biodegradability, thermosensitivity and easy controlled characters. This review stresses on the physicochemical property, stability and composition prospects of smart PEG/poly(lactic-co-glycolic acid) (PLGA) based thermoresponsive injectable hydrogels, recently utilized for biomedical applications. The manuscript also highlights the synthesis scheme and stability characteristics of these copolymers, which will surely help the researchers working in the same area. We have also emphasized the applied use of these smart copolymers along with their formulation problems, which could help in understanding the possible modifications related with these, to overcome their inherent associated limitations.
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Affiliation(s)
- Amit Alexander
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, C.G. 492010, India.
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Abstract
OBJECTIVES : Opioid detoxification with subsequent naltrexone is found to be an effective method as the first step in an abstinence-oriented approach. The aim of this study is to investigate the predictive value of variables for abstinence in opioid-dependent patients. METHODS : Opioid-dependent patients were followed up to 1 month after detoxification. Predictor variables were assessed at baseline, during detoxification, and at discharge. Primary outcome was abstinence assessed by analyzing urine samples and self-reports. Logistic regression was used to identify predictors of abstinence. RESULTS : Of 272 participants, 211 could be rated as abstinent (59.2%) or nonabstinent (40.8%) at 1 month follow-up. Significant baseline predictors were severity score of justice/police (ASI) and physical quality of life (SF-36); discharge predictors were general quality of health (SF-36) and sleeping problems (SCL-90); change in sleeping problems (SCL-90) during detoxification was also a predictor. The explained variance of these predictors was very low and clinical significance was limited. CONCLUSIONS : Considering the results it seems not possible to predict who will be abstinent or not 1 month after detoxification. Because rapid detoxification is found to be an effective detoxification method in selected patients, it seems warranted to recommend that patients with similar characteristics (ie, patients motivated for an abstinence-based treatment and low non-drug-related severity scores on the ASI) should be regarded as eligible for rapid detoxification.
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Khodaverdi E, Tekie FSM, Mohajeri SA, Ganji F, Zohuri G, Hadizadeh F. Preparation and investigation of sustained drug delivery systems using an injectable, thermosensitive, in situ forming hydrogel composed of PLGA-PEG-PLGA. AAPS PharmSciTech 2012; 13:590-600. [PMID: 22528547 DOI: 10.1208/s12249-012-9781-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 03/28/2012] [Indexed: 11/30/2022] Open
Abstract
In situ gelling systems are very attractive for pharmaceutical applications due to their biodegradability and simple manufacturing processes. The synthesis and characterization of thermosensitive poly(D,L-lactic-co-glycolic acid) (PLGA)-polyethylene glycol (PEG)-PLGA triblock copolymers as in situ gelling matrices were investigated in this study as a drug delivery system. Ring-opening polymerization using microwave irradiation was utilized as a novel technique, and the results were compared with those using a conventional method of polymerization. The phase transition temperature and the critical micelle concentration (CMC) of the copolymer solutions were determined by differential scanning calorimetry and spectrophotometry, respectively. The size of the micelles was determined with a light scattering method. In vitro drug release studies were carried out using naltrexone hydrochloride and vitamin B12 as model drugs. The rate and yield of the copolymerization process via microwave irradiation were higher than those of the conventional method. The copolymer structure and concentration played critical roles in controlling the sol-gel transition temperature, the CMC, and the size of the nanomicelles in the copolymer solutions. The rate of drug release could be modulated by the molecular weight of the drugs, the concentration of the copolymers, and their structures in the formulations. The amount of release versus time followed zero-order release kinetics for vitamin B12 over 25 days, in contrast to the Higuchi modeling for naltrexone hydrochloride over a period of 17 days. In conclusion, PLGA-PEG1500-PLGA with a lactide-to-glycolide ratio of 5:1 is an ideal system for the long-acting, controlled release of naltrexone hydrochloride and vitamin B12.
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Reece AS. Clinical safety of 1500 mg oral naltrexone overdose. BMJ Case Rep 2010; 2010:2010/sep06_1/bcr0420102871. [PMID: 22778191 DOI: 10.1136/bcr.04.2010.2871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case represents a clinical overdose of the largest known dose of oral naltrexone, equivalent to the taking of a whole bottle of the oral naltrexone preparation. The patient's intention was to control craving for alcohol and opiates. The patient quickly settled with expectant management. As such it demonstrates that earlier concerns that have been voiced in this area, particularly relating to naltrexone-related hepatotoxicity and depression, may have been overstated, at least in the experience of this patient. This patient's course was marked only by gastric irritation, of which she had some history. As such the present profile provides case report evidence consistent with more robust views of the patient safety of naltrexone itself, and opposing more cautious views. Her polydrug craving was suppressed for a period of 2 weeks, which raises the important question of the mechanism of action of naltrexone's generalised suppression of refractory hedonic consumptive addictive behaviours.
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11
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Gowing L, Ali R, White JM. Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal. Cochrane Database Syst Rev 2010; 2010:CD002022. [PMID: 20091529 PMCID: PMC7065589 DOI: 10.1002/14651858.cd002022.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Withdrawal (detoxification) is necessary prior to drug-free treatment or as the end point of long-term substitution treatment. OBJECTIVES To assess the effectiveness of opioid antagonists to induce opioid withdrawal with concomitant heavy sedation or anaesthesia, in terms of withdrawal signs and symptoms, completion of treatment and adverse effects. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2009), Medline (January 1966 to 11 August 2009), Embase (January 1985 to 2009 Week 32), PsycINFO (1967 to July 2009), and reference lists of articles. SELECTION CRITERIA Controlled studies of antagonist-induced withdrawal under heavy sedation or anaesthesia in opioid-dependent participants compared with other approaches, or a different regime of anaesthesia-based antagonist-induced withdrawal. DATA COLLECTION AND ANALYSIS One reviewer assessed studies for inclusion, undertook data extraction and assessed quality. Inclusion decisions and the overall process were confirmed by consultation between all authors. MAIN RESULTS Nine studies (eight randomised controlled trials) involving 1109 participants met the inclusion criteria for the review.Antagonist-induced withdrawal is more intense but less prolonged than withdrawal managed with reducing doses of methadone, and doses of naltrexone sufficient for blockade of opioid effects can be established significantly more quickly with antagonist-induced withdrawal than withdrawal managed with clonidine and symptomatic medications. The level of sedation does not affect the intensity and duration of withdrawal, although the duration of anaesthesia may influence withdrawal severity. There is a significantly greater risk of adverse events with heavy, compared to light, sedation (RR 3.21, 95% CI 1.13 to 9.12, P = 0.03) and probably with this approach compared to other forms of detoxification. AUTHORS' CONCLUSIONS Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone maintenance treatment. Given that the adverse events are potentially life-threatening, the value of antagonist-induced withdrawal under heavy sedation or anaesthesia is not supported. The high cost of anaesthesia-based approaches, both in monetary terms and use of scarce intensive care resources, suggest that this form of treatment should not be pursued.
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Affiliation(s)
- Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Robert Ali
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Jason M White
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
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Schroder KEE, Johnson CJ. Interactive voice response technology to measure HIV-related behavior. Curr HIV/AIDS Rep 2009; 6:210-6. [DOI: 10.1007/s11904-009-0028-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Arnold-Reed DE, O'Neil P, Holman CDJ, Bulsara MK, Rodiguez C, Gawthorne G, Tait RJ, Hulse GK. A Comparison of Mental Health Hospital Admissions in a Cohort of Heroin Users Prior to and After Rapid Opiate Detoxification and Oral Naltrexone Maintenance. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2009; 33:655-64. [PMID: 17891658 DOI: 10.1080/00952990701522666] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Mental health (MH) hospital admissions were investigated in a cohort (N=1184) of heroin dependent persons using linked health records. All MH in-patient admissions were extracted 36 months before to 36 months after commencing rapid opioid detoxification (ROD) and oral naltrexone. Results show that the incidence rate ratio (IRR) of drug-related and other MH admissions peaked in the 3 months immediately prior to treatment. All categories subsequently declined to baseline levels by 36 months following treatment. The authors conclude that treatment for heroin dependence reduces risk of MH admissions.
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Affiliation(s)
- D E Arnold-Reed
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, Western Australia
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Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. DIALOGUES IN CLINICAL NEUROSCIENCE 2008. [PMID: 18286804 PMCID: PMC3202507 DOI: 10.31887/dcns.2007.9.2/hkleber] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
While opioid dependence has more treatment agents available than other abused drugs, none are curative. They can, however, markedly diminish withdrawal symptoms and craving, and block opioid effects due to lapses. The most effective withdrawal method is substituting and tapering methadone or buprenorphine, α-2 Adrenergic agents can ameliorate untreated symptoms or substitute for agonists if not available. Shortening withdrawal by precipitating it with narcotic antagonists has been studied, but the methods are plagued by safety issues or persisting symptoms. Neither the withdrawal agents nor the methods are associated with better long-term outcome, which appears mostly related to post-detoxification treatment. Excluding those with short-term habits, the best outcome occurs with long-term maintenance on methadone or buprenorphine accompanied by appropriate psychosocial interventions. Those with strong external motivation may do well on the antagonist naltrexone. Currently, optimum duration of maintenance on either is unclear. Better agents are needed to impact the brain changes related to addiction.
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Affiliation(s)
- Herbert D Kleber
- Columbia University College of Physicians & Surgeons, New York, NY 10032, USA.
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Dijkstra BAG, De Jong CAJ, Bluschke SM, Krabbe PFM, van der Staak CPF. Does naltrexone affect craving in abstinent opioid-dependent patients? Addict Biol 2007; 12:176-82. [PMID: 17508990 DOI: 10.1111/j.1369-1600.2007.00067.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Naltrexone blocks the opioid receptors that modulate the release of dopamine in the brain reward system and therefore blocks the rewarding effects of heroin and alcohol. It is generally assumed that naltrexone leads to reduction of craving, but few studies have been performed to prove this. The purpose of the present study was to examine the effect of the administration of naltrexone on craving level after rapid opioid detoxification induced by naltrexone. A naturalistic study was carried out in which patients were followed during 10 months after rapid detoxification. Data about abstinence, relapse, and naltrexone use were collected by means of urine specimens. Craving was measured by the visual analogue scale craving, the Obsessive Compulsive Drug Use Scale, and the Desires for Drug Questionnaire. Results showed that patients who relapsed in opioid use experienced obviously more craving than abstinent people. Patients who took naltrexone did not experience significant less craving than those who did not. These results suggest that the use of opioids is associated with increased craving and that abstinence for opioids is associated with less craving, independent of the use of naltrexone. This is in contrast to the general opinion. Because of the naturalistic design of the study, no firm conclusions can be drawn, but the results grounded the needs of an experimental study.
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Affiliation(s)
- Boukje A G Dijkstra
- Novadic-Kentron, Network for Addiction Treatment Services, Sint-Oedenrode, The Netherlands.
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Maintenance Pharmacotherapy for Opioid Dependence and SF-36 Health Status: A Comparison With General Population Norms and Other Chronic Disorders. ADDICTIVE DISORDERS & THEIR TREATMENT 2006. [DOI: 10.1097/01.adt.0000210078.99735.27] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Roozen HG, de Waart R, van der Windt DAWM, van den Brink W, de Jong CAJ, Kerkhof AJFM. A systematic review of the effectiveness of naltrexone in the maintenance treatment of opioid and alcohol dependence. Eur Neuropsychopharmacol 2006; 16:311-23. [PMID: 16361086 DOI: 10.1016/j.euroneuro.2005.11.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2005] [Revised: 10/28/2005] [Accepted: 11/04/2005] [Indexed: 12/30/2022]
Abstract
This systematic review summarises evidence of the effectiveness of naltrexone (NTX) and the added value of psychosocial treatment in the maintenance treatment of opioid and alcohol dependence. Studies were selected through a literature search conducted in March 2004. Seven opioid and seventeen alcohol studies were identified. When possible, meta-(regression) analyses were performed. There is lack of evidence about the effectiveness of NTX in the maintenance treatment of opioid dependence. There is evidence for the effectiveness and applicability of NTX in the management of alcohol dependence. The opioid studies combined NTX with a variety of psychosocial interventions, which plagued the evaluation of their value. Concomitant psychosocial interventions used in the alcohol studies were mainly cognitive behavioural, which seems to be more effective than NTX combined with supportive therapy. Available data do not allow firm conclusions regarding the added effect of psychosocial interventions. However, the data suggest that a combination of naltrexone with cognitive behavioural relapse prevention therapy is beneficial in alcohol dependent patients.
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Affiliation(s)
- Hendrik G Roozen
- Novadic-Kentron, Network for Addiction Treatment Services, Roosendaal/Sint-Oedenrode, The Netherlands.
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Abstract
PURPOSE OF REVIEW This review summarizes current research on the management of opioid withdrawal and considers the selection of the approach in different situations. RECENT FINDINGS The recent publication of three controlled trials makes firm conclusions about the relative effectiveness of newer approaches (antagonist-induced withdrawal under anaesthesia or with minimal sedation; buprenorphine) to the management of opioid withdrawal possible. SUMMARY Antagonist-induced withdrawal under anaesthesia should not be pursued as it has an increased risk of life-threatening adverse events and has no additional benefits relative to antagonist-induced withdrawal under minimal sedation. Antagonist-induced withdrawal with minimal sedation is feasible and may be suitable for those who intend to enter antagonist-maintenance treatment with a clear commitment to abstinence and good support. Buprenorphine is suitable for quick withdrawal, supports transition to naltrexone maintenance treatment, is safe and effective in outpatient settings and can be extended into maintenance treatment if the detoxification attempt is unsuccessful. Adrenergic agonists (clonidine and lofexidine) remain an effective option for those who do not want to use an opioid and do not intend to transfer to naltrexone maintenance treatment, with lofexidine being preferable for outpatient settings. Through appropriate choice of approach, detoxification can be a gateway to multiple, long-term treatment options.
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Abstract
BACKGROUND Withdrawal (detoxification) is necessary prior to drug-free treatment. It may also represent the end point of long-term opioid replacement treatment such as methadone maintenance. The availability of managed withdrawal is essential to an effective treatment system. OBJECTIVES To assess the effectiveness of interventions involving the administration of opioid antagonists to induce opioid withdrawal with concomitant heavy sedation or anaesthesia, in terms of withdrawal signs and symptoms, completion of treatment and adverse effects. SEARCH STRATEGY We searched the Drugs and Alcohol Group register (October 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), Medline (January 1966 to January 2005), Embase (January 1985 to January 2005), PsycINFO (1967 to January 2005), and Cinahl (1982 to December 2004) and reference lists of studies. SELECTION CRITERIA Controlled trials comparing antagonist-induced withdrawal under heavy sedation or anaesthesia with another form of treatment, or a different regime of anaesthesia-based antagonist-induced withdrawal. DATA COLLECTION AND ANALYSIS One reviewer assessed studies for inclusion and undertook data extraction and assessed quality. Inclusion decisions and the overall process were confirmed by consultation between all three reviewers. MAIN RESULTS Six studies (five randomised controlled trials) involving 834 participants met the inclusion criteria for the review.Antagonist-induced withdrawal is more intense but less prolonged than withdrawal managed with reducing doses of methadone, and doses of naltrexone sufficient for blockade of opioid effects can be established significantly more quickly with antagonist-induced withdrawal than withdrawal managed with clonidine and symptomatic medications. The level of sedation does not affect the intensity and duration of withdrawal, although the duration of anaesthesia may influence withdrawal severity. There is a significantly greater risk of adverse events with heavy, compared to light, sedation (RR 3.21, 95% CI 1.13 to 9.12, P = 0.03) and probably also other forms of detoxification. AUTHORS' CONCLUSIONS Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone maintenance treatment. Given that the adverse events are potentially life-threatening, the value of antagonist-induced withdrawal under heavy sedation or anaesthesia is not supported. The high cost of anaesthesia-based approaches, both in monetary terms and use of scarce intensive care resources, suggest that this form of treatment should not be pursued.
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Affiliation(s)
- L Gowing
- University of Adelaide, Department of Clinical and Experimental Pharmacology, DASC Evidence-Bsed Practice Unit, Adelaide, Australia, 5005.
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Shanahan MD, Doran CM, Digiusto E, Bell J, Lintzeris N, White J, Ali R, Saunders JB, Mattick RP, Gilmour S. A cost-effectiveness analysis of heroin detoxification methods in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD). Addict Behav 2006; 31:371-87. [PMID: 15972245 DOI: 10.1016/j.addbeh.2005.05.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Revised: 05/03/2005] [Accepted: 05/13/2005] [Indexed: 11/24/2022]
Abstract
This economic evaluation was part of the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD) project. Data from four trials of heroin detoxification methods, involving 365 participants, were pooled to enable a comprehensive comparison of the cost-effectiveness of five inpatient and outpatient detoxification methods. This study took the perspective of the treatment provider in assessing resource use and costs. Two short-term outcome measures were used-achievement of an initial 7-day period of abstinence, and entry into ongoing post-detoxification treatment. The mean costs of the various detoxification methods ranged widely, from AUD 491 dollars(buprenorphine-based outpatient); to AUD 605 dollars for conventional outpatient; AUD 1404 dollars for conventional inpatient; AUD 1990 dollars for rapid detoxification under sedation; and to AUD 2689 dollars for anaesthesia per episode. An incremental cost-effectiveness analysis was carried out using conventional outpatient detoxification as the base comparator. The buprenorphine-based outpatient detoxification method was found to be the most cost-effective method overall, and rapid opioid detoxification under sedation was the most cost-effective inpatient method.
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Affiliation(s)
- M D Shanahan
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, NSW 2052, Australia.
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22
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Favrat B, Zimmermann G, Zullino D, Krenz S, Dorogy F, Muller J, Zwahlen A, Broers B, Besson J. Opioid antagonist detoxification under anaesthesia versus traditional clonidine detoxification combined with an additional week of psychosocial support: a randomised clinical trial. Drug Alcohol Depend 2006; 81:109-16. [PMID: 16024184 DOI: 10.1016/j.drugalcdep.2005.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2005] [Revised: 06/07/2005] [Accepted: 06/09/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND While detoxification under anaesthesia accelerates the detoxification procedure, there is a lack of randomised clinical trials evaluating its effectiveness compared to traditional detoxification procedures, and a lack of data on long-term abstinence. METHODS Prospective randomised clinical trial. Analysis by intention to treat and per protocol. SETTING Specialised substance abuse unit in a psychiatric teaching hospital and an intensive care unit of a general hospital. PARTICIPANTS Seventy patients with opiate mono-dependence requesting detoxification: 36 randomised to RODA (treatment as allocated received by 26) and 34 randomised to classical clonidine detoxification (treatment as allocated received by 21). MAIN OUTCOME MEASURES Successful detoxification, safety and self-reported abstinence at 3, 6 and 12 months after detoxification. RESULTS Socio-demographics were similar in both groups at baseline. No complications were reported during or after anaesthesia. According to the intention to treat analysis, 28/36 (78%) RODA patients and 21/34 (62%) of the clonidine group successfully completed the detoxification process (p=0.14). In the intention to treat analysis, 30% of RODA patients were abstinent after 3 months compared to 14% in the clonidine group (p=0.11). No difference was found at 6 and 12 months (both groups showed less than 5% abstinence after 12 months). The per-protocol analysis showed similar results with no statistical differences either for ASI mean scores or for the SF36 questionnaire. CONCLUSION Although the detoxification success rate and abstinence after 3 months were slightly better for the RODA procedure compared to clonidine treatment, these differences were not statistically significant and disappeared completely after 6 and 12 months.
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Affiliation(s)
- B Favrat
- Substance Abuse Division, Department of Psychiatry, University of Lausanne, Medical Outpatient Clinic, Bugnon 44, 1011 Lausanne, Vaud, Switzerland.
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23
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Digiusto E, Lintzeris N, Breen C, Kimber J, Mattick RP, Bell J, Ali R, Saunders JB. Short-term outcomes of five heroin detoxification methods in the Australian NEPOD Project. Addict Behav 2005; 30:443-56. [PMID: 15718062 DOI: 10.1016/j.addbeh.2004.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study included 380 participants in five heroin detoxification trials whose data were pooled to enable direct comparison of five detoxification methods in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD). Rapid detoxification achieved similar initial abstinence rates with either anaesthesia or sedation (average 59%), which were higher than was achieved by inpatient detoxification using clonidine plus other symptomatic medications (24%), which in turn was higher than outpatient detoxification using either buprenorphine (12%) or clonidine plus other symptomatic medications (4%). Older participants and those using more illicit drugs were more likely to achieve abstinence. Entry rates into ongoing postdetoxification treatment were as follows: buprenorphine outpatient (65%), sedation (63%), anaesthesia (42%), symptomatic outpatient (27%), and symptomatic inpatient (12%). Postdetoxification treatment with buprenorphine or methadone was preferred over naltrexone. Participants with more previous detoxification attempts were more likely to enter postdetoxification treatment. Given that outpatient detoxification was more effective with buprenorphine than with symptomatic medications and that rapid detoxification was more effective than the symptomatic inpatient method, the roles of the symptomatic methods should be reconsidered.
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Affiliation(s)
- Erol Digiusto
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia.
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De Jong CAJ, Laheij RJF, Krabbe PFM. General anaesthesia does not improve outcome in opioid antagonist detoxification treatment: a randomized controlled trial. Addiction 2005; 100:206-15. [PMID: 15679750 DOI: 10.1111/j.1360-0443.2004.00959.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Opioid detoxification by administering opioid-antagonists under general anaesthesia has caused considerable controversy. This study is conducted to determine whether rapid detoxification under general anaesthesia results in higher levels of opioid abstinence than rapid detoxification without anaesthesia. DESIGN Randomized controlled open clinical trial from September 1999 to August 2001. SETTING Four addiction centres in collaboration with three general hospitals in the Netherlands. PARTICIPANTS A total of 272 opioid-dependent patients whose previous attempts to abstain were unsuccessful. INTERVENTION Patients received rapid detoxification with general anaesthesia (RD-GA) or without general anaesthesia (RD). MEASUREMENTS Urine screens and an interview (EuropASI) to assess opioid abstinence; two questionnaires (SOOS, OOWS) to measure withdrawal symptoms and one to measure craving (VAS). FINDINGS One month after the intervention 62.8% of the patients in the RD-GA group and 60.0% in the RD group were abstinent for opioids (P = 0.71). No adverse events or complications occurred during RD; however, in the RD-GA group, five adverse events necessitated admission to a general hospital. The average 1-month cost for RD was Euros 2517 versus Euros 4439 for RD-GA. CONCLUSIONS Rapid detoxification under general anaesthesia did not result in higher levels of opioid abstinence than rapid detoxification without anaesthesia. The cost of the former intervention was much higher.
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Affiliation(s)
- Cor A J De Jong
- Novadic-Kentron-Network for Addiction Treatment Services, Nijmegen Institute for Scientist-Practitioners in Addiction, Radboud University Nijmegen, Nijmegen, Netherlands.
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Digiusto E, Shakeshaft A, Ritter A, O'Brien S, Mattick RP. Serious adverse events in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD). Addiction 2004; 99:450-60. [PMID: 15049745 DOI: 10.1111/j.1360-0443.2004.00654.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS The study estimated serious adverse event (SAE) rates among entrants to pharmacotherapies for opioid dependence, during treatment and after leaving treatment. DESIGN A longitudinal study based on data from 12 trials included in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD). PARTICIPANTS AND SETTINGS A total of 1244 heroin users and methadone patients treated in hospital, community and GP settings. Intervention Six trials included detoxification; all included treatment with methadone, buprenorphine, levo-alpha-acetyl-methadol (LAAM) or naltrexone. FINDINGS During 394 person-years of observation, 79 SAEs of 28 types were recorded. Naltrexone participants experienced 39 overdoses per 100 person-years after leaving treatment (44% occurred within 2 weeks after stopping naltrexone). This was eight times the rate recorded among participants who left agonist treatment. Rates of all other SAEs were similar during treatment versus out of treatment, for both naltrexone-treated and agonist-treated participants. Five deaths occurred, all among participants who had left treatment, at a rate of six per 100 person-years. Total SAE rates during naltrexone and agonist treatments were similar (20, 14 per 100 person-years, respectively). Total SAE and death rates observed among participants who had left treatment were three and 19 times the corresponding rates during treatment. CONCLUSIONS Individuals who leave pharmacotherapies for opioid dependence experience higher overdose and death rates compared with those in treatment. This may be due partly to a participant self-selection effect rather than entirely to pharmacotherapy being protective. Clinicians should alert naltrexone treatment patients in particular about heroin overdose risks. Duty of care may extend beyond cessation of dosing.
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Affiliation(s)
- E Digiusto
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
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Ali R, Thomas P, White J, McGregor C, Danz C, Gowing L, Stegink A, Athanasos P. Antagonist-precipitated heroin withdrawal under anaesthetic prior to maintenance naltrexone treatment: determinants of withdrawal severity. Drug Alcohol Rev 2004; 22:425-31. [PMID: 14660132 DOI: 10.1080/09595230310001613949] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study sought to characterize antagonist-precipitated heroin withdrawal during and immediately following anaesthesia and to identify the determinants of withdrawal severity and duration in 48 dependent heroin users. Objective withdrawal signs decreased significantly with each naloxone bolus administered under anaesthetic. The cost (amount) of the final heroin administration and the number of hours between last heroin use and commencement of anaesthesia were significant, independent predictors of the severity of withdrawal symptomatology. While 83% (40/48) of participants completed withdrawal according to objective criteria and commenced maintenance naltrexone treatment, almost half (22/48) were unable to commence naltrexone on the day of the procedure due to residual withdrawal signs. Fourteen of these 22 participants subsequently commenced naltrexone (median number of days between admission and commencement of naltrexone was 2, range 1 - 6) while eight left treatment prior to initiation of naltrexone. Significantly fewer of those with more severe withdrawal signs during anaesthesia commenced naltrexone (40% vs. 60%). While the severity and duration of withdrawal symptomatology may be moderated by encouraging participants to reduce (or cease) heroin use close to the time of withdrawal, for a substantial proportion of participants in this study, heroin withdrawal by this antagonist-precipitated procedure was neither rapid nor painless. [Ali R, Thomas P, White J, McGregor C, Danz,C, Gowing L, Stegink A, Athanasos P. Antagonist-precipitated heroin withdrawal under anaesthetic prior to maintenance naltrexone treatment: determinants of withdrawal severity.
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Affiliation(s)
- Robert Ali
- Department of Clinical and Experimental Pharmacology, University of Adelaide, South Australia.
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Abstract
This review covers beta-phenylethylamines and isoquinoline alkaloids derived from them, including further products of oxidation. condensation with formaldehyde and rearrangement, some of which do not contain an isoquinoline system, together with naphthylisoquinoline alkaloids, which have a different biogenetic origin. The occurrence of the alkaloids, with the structures of new bases, together with their reactions, syntheses and biological activities are reported. The literature from July 2002 to June 2003 is reviewed, with 568 references cited.
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Abstract
This paper is the twenty-fifth consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2002 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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Gandhi DH, Jaffe JH, McNary S, Kavanagh GJ, Hayes M, Currens M. Short-term outcomes after brief ambulatory opioid detoxification with buprenorphine in young heroin users. Addiction 2003; 98:453-62. [PMID: 12653815 DOI: 10.1046/j.1360-0443.2003.00334.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS This study examines the outcomes at 1, 3 and 6 months after a very brief outpatient detoxification with buprenorphine in 18-25-year-old heroin users. DESIGN Prospective follow-up study. SETTING Outpatient drug treatment clinic, providing brief detoxification in downtown Baltimore, Maryland, USA. PARTICIPANTS One hundred and twenty-three subjects between 18 and 25 years old; 56% male; 95% Caucasian; seeking detoxification; living in Baltimore City and five surrounding counties. INTERVENTION Detoxification with buprenorphine over 3 days. Follow-up at 1, 3 and 6 months. MEASUREMENTS Drug use history, the Addiction Severity Index at baseline and follow-up, urine drug screens, evaluation of the detoxification experience. FINDINGS By self-report, 37% of the total sample were not currently using heroin at 1 month, 32% at 3 months and 29% at 6 months, and 6.7%, 10.1% and 11.8% had an opioid negative urine test at 1, 3 and 6 months, respectively. There was a significant reduction from the baseline in mean Addiction Severity Index drug use composite score, as well as the mean number of days of heroin and cocaine use during past 30 days, that was sustained over the three follow-up points. Engagement in aftercare was generally poor. CONCLUSIONS The findings show a reduced frequency and intensity of drug use, suggesting a possible role for brief outpatient detoxification in reducing the severity of dependence for some younger heroin users who may not yet be ready to engage in long-term abstinence-oriented or opioid substitution treatments.
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Affiliation(s)
- Devang H Gandhi
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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