Pharmacologic treatments for opioid dependence: detoxification and maintenance options

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. alpha-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.

Patient views of opioid pharmacotherapy biodelivery systems: Qualitative study to assist treatment decision making.

“…Keywords: opioid pharmacotherapy (OPT), heroin users, treatment, decision making, qualitative Opioid pharmacotherapy (OPT) is an effective and evidencebased approach to treating opioid dependence (Bell, 2012;National Institute for Health and Clinical Excellence, 2007; Substance Abuse and Mental Health Services Administration, 2018; World Health Organization, United Nations Office on Drugs and Crime, & Joint United Nations Programme on HIV and AIDS, 2004). There is an extensive literature evaluating and comparing different types of OPT, but studies are largely confined to analyses of detoxification versus maintenance, and assessments of specific medicines, such as methadone, buprenorphine, lofexidine, levomethadyl acetate, and naltrexone (Kleber, 2007;Mattick, Breen, Kimber, & Davoli, 2014;Stotts, Dodrill, & Kosten, 2009). While most of this literature is based on biomedical or clinical studies, social scientists have used qualitative and quantitative methods to capture both treatment provider perspectives (e.g., Berg, Arnsten, Sacajiu, & Karasz, 2009;Eversman, 2010;Larance et al, 2011;Lin et al, 2010;Philbin & Zhang, 2010) and patient perspectives (e.g., Anstice, Strike, & Brands, 2009;Conner & Rosen, 2008;Harris & McElrath, 2012;Lin, Wu, & Detels, 2011;Nyamathi et al, 2007;Treloar, Fraser, & Valentine, 2007).…”

Methadone, Buprenorphine, and Clonidine Attenuate Mitragynine Withdrawal in Rats

“…It was reported to cause rebound hypertensive episodes in long-term clonidine therapy but proved as safe in short-term use ( Kariya et al, 1998 ). Kleber (2007) also showed that clonidine can be used to treat residual mild withdrawal symptoms for a few days to a week as long as the patient does not become hypotensive. Nevertheless, clonidine has been reported to be less effective compared to methadone during early opioid detoxification phase when withdrawal symptoms were more pronounced and patients more likely to drop out ( Mattick and Hall, 1996 ).…”

“…Methadone and buprenorphine are both opioids, acting fully and partially on mu-opioid receptor, respectively ( Kleber, 2007 ). Methadone and buprenorphine have been approved by the FDA in opioid replacement therapy ( Bart, 2012 ).…”

“…It has analgesic effects ( Kariya et al, 1998 ) and has been reported to decrease opioid dosage without affecting the quality of analgesia ( Rostaing et al, 1991 ). It can reduce opiate withdrawal signs in inpatient and outpatient settings ( Washton and Resnick, 1981 ; Tierney et al, 1988 ), via binding to α 2 -autoreceptors in the locus coeruleus and suppressing hyperactivity during withdrawal ( Kleber, 2007 ). However, clonidine has adverse effects, particularly hypotension, which can restrict optimal clonidine dose for opioid withdrawal.…”

Medication Treatment for Opioid Use Disorders:

“…A third medication is naltrexone, a µ-opioid receptor antagonist that blocks exogenous opioids and the euphoric effects of heroin and other opioids. 1 One 50 mg oral dose provides opioid blockade for 24-36 hours, and long-term use does not cause tolerance to its blocking effect or withdrawal after it is discontinued. 2 …”