Illicit Opiate Use Research Articles

Buphrenorphine: Detoxification After Maintenance Treatment

Abstract: Buprenorphine, a partial opiate agonist, has shown promise as a new drug for the maintenance, treatment and detoxification of heroin addictions. In this double blind study 15 outpatient heroin addicts were stabilised on sublingual buprenorphine (4mg/day) and then the effects of a 30 day gradual detoxification were assessed. For the first 2 weeks of the study, while taking 4mg of buprenorphine subjects reported symptoms of opiate intoxication and withdrawal, 2–4 and 8–9 hours respectively after each day's dose. During this time 12 of the 15 subjects had one or more opiate positive urine specimens and 48% of all urine specimens were opiate positive. As detoxification progressed subjects reported an earlier onset and a greater number of withdrawal symptoms. In addition they requested symptomatic treatment. The prescription of dextropropoxyphene napsylate (up to 800mg per day) and clonidine hydrochloride (up to 450mcg per day) controlled the subjects' withdrawal discomfort. Of the 6 subjects who completed the detoxification and the two‐week follow‐up period, 5 had one or more opiate positive urine specimens and 57% of all specimens were opiate positive. The study has shown that sublingual buprenorphine is acceptable to outpatient heroin addicts and that a gradual withdrawal of the drug can be undertaken successfully. However, the results suggest that doses greater than 4mg/day will be needed to suppress illicit opiate use.

Contingent methadone delivery: Effects on illicit-opiate use

This study examined the effects of contingent vs. non-contingent delivery of a methadone dose supplement on relapse to illicit opiate use in the context of a methadone outpatient detoxification program. Following a 3-week methadone stabilization period on 30 mg, patients ( N = 39) were randomly assigned to a contingent, a non-contingent, or a control treatment group. All patients received identical gradual reductions in their assigned methadone dose. During the dose reduction period (weeks 4–11), members of the contingent ( N = 13) and non-contingent groups ( N = 13) could obtain daily methadone-dose supplements up to 20 mg, but contingent group members could obtain supplements only if their most recent urinalysis results were opiate negative. Control subjects ( N = 13) did not have dose increases available. The contingent group presented significantly lower opiate-positive urines during weeks 8–11 (14% positive) of the detox than the non-contingent (38% positive) or control (50% positive) groups. Additionally, the availability of extra methadone improved treatment retention and increased clinic attendance above levels observed in the control group. The potential for further use of methadone's reinforcing properties in the treatment of opiate dependence is discussed.

Methadone and Naltrexone in the Treatment of Heroin Dependence

Over the past 20 years, methadone maintenance has been shown to be a safe, effective treatment for large numbers of heroin addicts. The majority of patients derive major benefits while in treatment, most measurably in the areas of decreased use of illicit opiates, diminished criminality, increased levels of employment and more stable interpersonal relationships. An advantage of methadone maintenance over other treatments is that it attracts and retains a relatively large segment of the addict population and is reasonably cost-effective. Naltrexone is well suited as a transitional treatment for individuals who have progressed using methadone maintenance. Patients completing a course of methadone maintenance should be encouraged to use naltrexone during the postmethadone period, when symptoms of protracted abstinence often lead them to reinitiate use of heroin. Those with stable family relationships, good jobs, minimal antisocial behavior, and low drug-craving before beginning a course of naltrexone appear to benefit most from the treatment. Rates of retention improve when naltrexone is used within a comprehensive rehabilitation program. Although addicted individuals are often stereotyped, they are, in fact, a heterogeneous group representing a range of psychopathologies and life situations. Thus, within any one facility, a variety of modalities should be available to allow treatment to be tailored to the individual. No single treatment is best for all patients, and, moreover, the preferred modality for any one individual may change over time as a result of progress in treatment or varying life circumstances. Multimodality programs that include methadone and naltrexone enable the maximal number of individuals to benefit from treatment.

Chronic opiate use during methadone detoxification: Effects of a dose increase treatment

The effects of administering high methadone doses during detoxification treatment were examined on illicit opiate use and treatment retention in chronic opiate supplementors. Twenty-six applicants to a 90-day outpatient detoxification program who delivered 50% or more opiate-positive urine samples during treatment weeks 2 and 3 were randomly assigned to receive a constant 30-mg dose through treatment week 10 or an increase to 60 mg in week 4 with gradual reduction to 30 mg by week 10. Dosage for both groups was reduced to 0 mg during weeks 11–13. Treatment retention was better for experimental (median = 86 days) than for control (median = 41 days) subjects, but the difference was not statistically significant. In the dose increase group, percent opiate-positive urines decreased from 80% to 62% during the first two weeks of dose increase ( t = 2.39, P < 0.05); opiate positive rates for the control group remained above 80%. A 20% between group difference in percent of opiate positive urine tests persisted through study week 10 in subjects ( N = 5 control, 7 experimental) who remained in treatment this long. Although the blind dose increase did improve treatment outcome, we concluded that the magnitude of the effect in this population of chronic opiate supplementors was insufficient to judge the procedure clinically useful.

Chronic heroin use during methadone treatment: A test of the efficacy of high maintenance doses

A pilot study was conducted at two maintenance programs to test the effect of increasing the methadone dose of clients who continue chronic heroin use after stabilization on methadone. Program 1 subjects (Group 1) received substantial dose increases for a 14-week period; Program 2 subjects (Group 2) received no dose modifications during the same period. Results show Group 1 reported an alleviation of physical and psychological complaints but did not decrease illicit opiate use. Group 2 maintained the low level of complaints reported at baseline and, unexpectedly, decreased opiate abuse. Because the two maintenance programs differed in clinical practices and in enforcement of rules, it was concluded that clients who continue chronic heroin use need not only long-term dosage increases, but also clear, consistently applied program policies.

Treatment outcome in methadone detoxification: Relationship to initial levels of illicit opiate use

Two groups each of 10 patients enrolled in a 90-day outpatient detoxification program were classified on the basis of high (92.5% of tests) and low (7.5% of tests) rates of opiate-positive urine test results during two weeks of dosage stabilization. Pretreatment demographic variables did not differ between the two groups. Relapse to opiate use during the detoxification occurred in patients who were initially opiate free. By the end of the dose reduction period, opiate-positive rates were 60% and 87% of tests for the low and high opiate use groups, respectively. Sedative use and missed clinic days showed similar trends for both groups during the detoxification, although different patterns of drop-out from treatment were noted. Symptomatology increased during dose reduction for the low- but not for the high-frequency opiate group. In general, treatment outcome appeared equally poor for patients who showed low or high levels of illicit opiate drug use early in detoxification treatment.

Oral methadone self-administration: effects of dose and alternative reinforcers.

We examined the efficacy of oral methadone as a reinforcer by offering methadone maintenance patients the chance to self-administer extra doses of methadone occasionally in addition to their regular dose. Seven maintenance patients received twice-weekly choices between methadone doses or money. Doses were 0, 1, 5, 10, 25, or 50 mg methadone; the alternative money option was $1 or $5. Extra methadone doses were reliably self-administered by maintenance patients, and percent of dose choices rose as the size of the dose offered increased. Thus extra methadone doses functioned as reinforcers in this situation. Further, across the entire dose range, more dose choices were selected when $1 was offered than when $5 was offered as an alternative. Thus methadone self-administration was influenced by the alternative reinforcers available for drug refusal. Neither reports of subjective withdrawal symptoms nor reduction of symptoms after extra methadone predicted methadone self-administration, but dose selections were more likely when urinalysis results indicated recent illicit opiate use. The reinforcing effects of oral methadone in methadone-tolerant patients may be an important factor in the popularity of this treatment among drug abusers and in the long-term treatment retention generally observed during methadone maintenance.

Natural Recovery from Addiction: Some Social-Psychological Processes of Untreated Recovery

This is a report of an exploratory in-depth study of the social-psychological processes of untreated recovery. Data for the study comes from focused interviews with a sample of 201 ex-addicts (half untreated, half treated) located by means of the snowball referral method. Findings indicate that personal motivations to stop using opiates usually arise out of the lifestyle, police activities and environment of illicit opiate use—out of the “changes” addicts experience trying to maintain expensive habits. Individuals respond differently to such changes. Some sink into profound despair and act when they are forced to. Others weigh the consequence of future opiate use and make rational decisions to change, while still others just drift into something else because their commitment to opiate use and the lifestyle was only tenuous. Once addicts decide to quit, they must leave the scene, break all ties with opiate users and create new interests, new social networks, new social identities. Some persons do this by their own efforts while others use existing institutions. Six patterns of recovery were discerned and it was concluded that the “maturing out” concept is not sufficient to describe all the different variations. In addition to maturation, we found that some addicts become converts to religious, social or communal causes, some retire (give up the drug but maintain the lifestyle). Others use opiates in certain situations and change when the situation changes and some move on to other drugs (usually alcohol).

Client initiative, inertia, and demographics: more powerful than treatment interventions in methadone maintenance?

A major treatment intervention, previously reported in the literature, was conducted in which methadone clients were able to regulate their maintenance dose on a weekly basis. In this paper, the relationships among the intervention outcomes, demographic and personality variables, and treatment assignment are presented. The analyses indicate that personality, demographic, drug career, and treatment history variables did not interact with treatment assignment to produce particular outcomes. Nevertheless, outcome could be predicted by baseline illicit opiate use, prestudy methadone dosage, an interaction of age and ethnicity, and variables related to clients' initiative versus inertia with regard to treatment.

Allowing methadone clients control over dosage: A 48-week controlled trial

Two strategies for client self-regulation of dosage in methadone maintenance were examined in a 48-week randomized clinical trial. Subjects assigned to the two experimental conditions (SR-1 and SR-2) were able to regulate their dosage weekly. In addition, SR-2 subjects could earn additional take-home dose privileges by reducing dosage. A total of 85 subjects were randomly assigned to either SR-1 ( n = 28), SR-2 ( n = 31), or a standard treatment control condition ( n = 26). An anomalous trend for female control subjects to lower their dosage was observed, but otherwise dosage trends over time were similar in all treatments. Nevertheless, control subjects showed more illicit opiate use than either self-regulation group. Results confirm that methadone maintenance clients act responsibly when given the ability to regulate their own dosage. The opportunity for an increased number of take-home doses and the convenience of less frequent clinic visits seems not to be an adequate incentive to induce clients to significantly decrease their ongoing maintenance dosage.

Self-regulation of dose in methadone maintenance with contingent privileges

Abstract The effect of giving methadone maintenance clients the opportunity to regulate their dosage and of offering take-home doses as an incentive for dose reduction was studied. Subjects (116) were randomly assigned to one of three conditions: self-regulation ofdose (SR-1); self-regulation of dose with incentive for reduction (SR-2) and standard treatment (control). Dependent variables were dosage and use of illicit drugs (measured by urinalyses). Results for the first four months show SR-1 subjects increased dose and maintained themselves at dosages significantly greater than the SR-2 or control groups while having significantly less use of illicit opiates during certain time periods. SR-2 subjects were not different from controls. Findings indicate subjects behaved responsibly under self-regulation and that this regimen is clinically feasible. Nevertheless, an increase in take-home privileges was an insufficient incentive to yield major reductions in dosage in SR-2 as a group.

Illicit opiat use during methadone maintenance.

The core hypothesis deduced from the Dole-Nyswander blockade formulation is that methadone is a sufficient but not necessary condition for abstinence from heroin. It is argued that this hypothesis has not been tested with scientifically adequate research. A research design is suggested. Since the Dole-Nyswander focus is at the physiological and metabolic level, it is argued that the blockade theory, pending, its scientific validation, should be supplemented by sociological, organizational, and economic theory.

Control of Methadone Dosage by Patients

Patients in a methadone clinic were given knowledge and control of their own dosages. Dosages could be changed by 5 mg/week, but if more than 50 mg was used, no take-home privileges were allowed. The maximum dosage permitted was 120 mg. Plasma methadone levels were determined for some patients. The result of the study was that there was little dosage change, with the median dosage increasing from 40 to 50 mg at the end of six months. A small group of patients did raise their dosages systematically, and these patients tended to decrease illicit opiate use. There was no indication that these patients had abnormally low plasma methadone levels. At the end of six months, patients and staff overwhelmingly preferred an open-dose self-adjustment system over the usual procedure of dosage management by professional staff and dosage changes achieved by negotiation.

Plasma levels and symptom complaints in patients maintained on daily dosage of methadone hydrochloride.

Plasma methadone levels, symptom complaints, and urine tests for illicit opiate use were followed weekly in 17 patients on a methadone maintenance program. There were very large differences between patients in the plasma level established at a given dosage, implying large differences in the rate of methadone metabolism. Despite virtually constant daily dosage, the plasma methadone levels fluctuated greatly from week to week and from day to day in individual patients. With rate exceptions there was no relationship between plasma methadone level and symptom complaints or between weekly chamges in plasma methadone level and changes in symptom complaints. Except possible to identify the ocassional patient with unusually low plasam methadone levels, the determination of methadone levels is not likely to be or practical value in methadone programs.