Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal

Gowing, Linda; Ali, Robert; White, Jason M.

doi:10.1002/14651858.cd002022.pub3

Cited by 47 publications

(22 citation statements)

References 77 publications

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“…45 Rapid withdrawal and sedation assisted transition to opioid antagonist therapy has increased risk of serious adverse events when performed under heavy sedation and is too resource intensive to endorse given the limited benefit when performed under light sedation. 46,47 Longer period of detoxification (1–6 months) with methadone or buprenorphine are also ineffective in promoting abstinence beyond the initial stabilization period. 48,49 …”

Section: Medically Assisted Detoxificationmentioning

confidence: 99%

Maintenance Medication for Opiate Addiction: The Foundation of Recovery

Bart

2012

Journal of Addictive Diseases

400

283

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Illicit use of opiates is the fastest growing substance use problem in the United States and the main reason for seeking addiction treatment services for illicit drug use throughout the world. It is associated with significant morbidity and mortality related to HIV, hepatitis C, and overdose. Treatment for opiate addiction requires long-term management. Behavioral interventions alone have extremely poor outcomes, with more than 80% of patients returning to drug use. Similarly poor results are seen with medication assisted detoxification. This article provides a topical review of the three medications approved by the FDA for long-term treatment of opiate dependence: the opioid agonist methadone, the opioid partial agonist buprenorphine, and the opioid antagonist naltrexone. Basic mechanisms of action and treatment outcomes are described for each medication. Results indicate that maintenance medication provides the best opportunity for patients to achieve recovery from opiate addiction. Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function. Oral naltrexone is ineffective in treating opiate addiction but recent studies using extended release naltrexone injections have shown promise. While no direct comparisons between extended release naltrexone injections and either methadone or buprenorphine exist, indirect comparison of retention shows inferior outcome compared to methadone and buprenorphine. Further work is needed to compare directly each medication and determine individual factors that can assist in medication selection. Until such time, selection of medication should be based on informed choice following a discussion of outcomes, risks, and benefits of each medication.

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Section: Medically Assisted Detoxificationmentioning

confidence: 99%

Maintenance Medication for Opiate Addiction: The Foundation of Recovery

Bart

2012

Journal of Addictive Diseases

400

283

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“…Generally these approaches also employ α -2 antagonists (e.g., clonidine) and other adjunctive medications (e.g., antiemetics). While they may increase the likelihood of successful naltrexone induction compared with gradual opioid agonist or clonidine taper, there is no consistent evidence that they produce better outcomes than the more gradual approaches outlined above (33,65–67). Furthermore, ultrarapid induction procedures have produced life-threatening adverse events including aspiration pneumonia, pulmonary edema, diabetic ketoacidosis, and sudden death (33).…”

Section: Detoxification With Clonidine and Other Nonopioid Medicationsmentioning

confidence: 99%

“…Patients may also still experience weeks of withdrawal symptoms and the acute stress response is very high, as indicated by markedly elevated plasma adrenocorticotropic hormone, cortisol, and epinephrine levels (68,69). Thus, ultrarapid detoxification cannot be recommended, as it has no clear advantage over more gradual methods and may be medically dangerous (33,67,69–71). …”

Section: Detoxification With Clonidine and Other Nonopioid Medicationsmentioning

confidence: 99%

Opioid Detoxification and Naltrexone Induction Strategies: Recommendations for Clinical Practice

Sigmon

Bisaga

Nunes

et al. 2012

The American Journal of Drug and Alcohol Abuse

108

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Background Opioid dependence is a significant public health problem associated with high risk for relapse if treatment is not ongoing. While maintenance on opioid agonists (i.e., methadone, buprenorphine) often produces favorable outcomes, detoxification followed by treatment with the μ-opioid receptor antagonist naltrexone may offer a potentially useful alternative to agonist maintenance for some patients. Method Treatment approaches for making this transition are described here based on a literature review and solicitation of opinions from several expert clinicians and scientists regarding patient selection, level of care, and detoxification strategies. Conclusion Among the current detoxification regimens, the available clinical and scientific data suggest that the best approach may be using an initial 2–4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3–5 days up to the target dose of naltrexone. However, more research is needed to empirically validate the best approach for making this transition.

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“…The few randomized controlled trials in this area have not shown opioid antagonist detoxifi cation under anaesthesia to be superior to other treatments (De Jong 2005;Favrat et al 2006). Taking into account the medical risks of the procedure (particularly those related to general anaesthesia in patients who may be dependent on multiple kinds of drugs) and other safety concerns (Gowing et al 2010) , this method cannot be recommended and should not be used (NICE 2007).…”

Section: Rapid Detoxifi Cation Using Naltrexone In Combination With Cmentioning

confidence: 99%