Maintenance

After detoxification, relapse prevention must be actively addressed with whatever treatment interventions are available.

Unfortunately, a large percentage of addicts seem unable to tolerate acute withdrawal, to succeed at controlled detoxification, or to remain drug free. Methadone maintenance may then become the treatment of choice. Administered on a once-a-day schedule, methadone in appropriate doses blocks opioid withdrawal, thus reducing compulsive drug-seeking behavior and use. The individual may then focus energy and attention on more productive behaviors. Indications for the use of methadone maintenance include (1) a history of chronic, high-dose opioid abuse; (2) repeated failures at abstinence; (3) history of prior successful methadone maintenance; (4) history of drug-related criminal convictions or incarcerations; (5) pregnancy, especially first and third trimesters; and (6) HIV seropositivity.

Relative contraindications to methadone maintenance include (1) age less than 16 years, (2) the expectation of incarceration within 30-45 days, and (3) history of abuse of methadone maintenance, including diversion of methadone to "the street" and failure to cease illicit use despite adequate doses.

The administration of methadone, as noted earlier, is heavily regulated by Federal and state governments. Specific requirements must be met by individuals and clinics offering this service. Generally, after the individual's history and physical condition are assessed, methadone dosing begins according to the protocol previously described. A period of 4-10 days may be required to stabilize the patient at an appropriate dose. When stabilization has occurred, the individual's illicit drug use should cease, as evidenced by regular, monitored urinal-ysis showing only methadone. Methadone maintenance programs that maintain an overall average dose of 60-100 mg a day yield consistently better results in decreasing illicit opioid use. Doses in excess of 120 mg a day are seldom needed (Gerstein, 1990). A pitfall here is that individuals may supplement their maintenance dose with "black market" methadone. Urinalyses will not be helpful in detecting this behavior, since quantification techniques are not generally employed. Dosage requirements should not change after stabilization, unless something has occurred to change the body's absorption, metabolism, distribution, or excretion of methadone. Emesis within 20-30 minutes after the oral ingestion of methadone is an obvious example of disruption to absorption. Metabolism of methadone may be increased by the use of phenytoin, rifampin, barbiturates, carbamazepine, and some tricyclic antidepressants, all of which can precipitate withdrawal symptoms by reducing methadone plasma levels. Concealed regular use of other opiates in addition to methadone will result in the user's asking for more methadone, because the development of tolerance has outpaced current stable dosing. Abusive use of alcohol and/or benzo-diazepines with methadone maintenance will also cause individuals to request more methadone, possibly because of enhanced hepatic metabolism and/or significant withdrawal symptoms from these agents that do not share cross-tolerance with methadone. Administering disulfiram with methadone is a common and highly useful therapeutic approach.

Some individuals report that heavy labor with much perspiration reduces the effectiveness of methadone in a 24-hour period. This phenomenon is usually easily addressed with a small increase in dose, unless the individual is not being truthful. After months or years of methadone maintenance, most individuals are able to tolerate a slow taper of a few milligrams per week or month. For those persons who become suspicious or psychologically unstable as their dose is lowered, a "blind" detoxification schedule may be used, in which the individual never knows the exact amount of methadone he or she is receiving.

Pregnancy is a special situation for which continued methadone maintenance is recommended, because any withdrawal symptoms place the fetus at risk for spontaneous abortion (Finnegan, 1979). In addition, relapse to street drugs after detoxification also places the fetus at risk. Therefore, maintenance at a level of 20 mg is the safest plan. Slow detoxification down to this level can be achieved safely during the second trimester.

Other agents may be useful in maintenance of opioid users. Safety, regulatory, and political concerns unfortunately have limited the availability of methadone maintenance, so that a significant number of opiate dependent individuals who might benefit from this therapy fail to receive it. Because of these problems, the federal government in 2003 approved buprenorphine for use in the treatment of opiate withdrawal and maintenance. As previously discussed, buprenorphine is a long half-life (24 hours), mixed opiate agonist-antagonist. A dose of 8-16 mg of sublingual buprenorphine (Subutex) administered daily for 2-4 days can be extremely effective in ameliorating withdrawal symptoms (Bickel et al., 1988). For maintenance treatment, this same dose of sublingual buprenorphine (in combination with naltrexone to prevent street value, marketed as Suboxone) has been shown to be equivalently effective to methadone and LAAM in preventing relapse (Johnson et al., 2000; Mattick et al., 2003; Petitjean et al., 2001). Unlike methadone and LAAM, buprenorphine may be prescribed in the general office setting by practitioners specially qualified through the Drug Enforcement Agency. Currently, candidates for qualification are those practitioners who are either subspecialty boarded in addiction psychiatry, or who have received 8 hours of training through the American Academy of Addiction Psychiatry or the American Society of Addiction Medicine.

A pharmacological agent in the form of an opioid antagonist can be a useful adjunct in relapse prevention. A long-acting antagonist such as naltrexone (ReVia) is effective in blocking the euphoric effects of opioids and ultimately leads to the extinction of operantly conditioned drug-seeking behaviors. Naltrexone is given orally in the opioid-free individual three times a week in doses of 50-150 mg, and it blocks the effects of relatively large doses of opioids (John son & Strain, 1999). This adjunctive therapy works best in the context of ongoing treatment and support. Its administration should be monitored over time, because compliance with voluntary, unsupervised self-administration of naltrexone is notoriously poor. Length of treatment with this agent is a therapeutic issue having mainly to do with the individual's ability to embrace a drug-free lifestyle consistently over time. Because of the significant risk of developing hepatitis during naltrexone treatment, monitoring of liver function tests is important.

Detox Diet Basics

Detox Diet Basics

Our internal organs, the colon, liver and intestines, help our bodies eliminate toxic and harmful  matter from our bloodstreams and tissues. Often, our systems become overloaded with waste. The very air we breathe, and all of its pollutants, build up in our bodies. Today’s over processed foods and environmental pollutants can easily overwhelm our delicate systems and cause toxic matter to build up in our bodies.

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