Pharmacological Treatment Approaches

The most common and first-line treatment approach is to try to get the addict to stop using heroin by detoxification. Detoxification refers to using medications to treat withdrawal symptoms. The heroin withdrawal symptoms are similar to the symptoms of a severe flu. Although these withdrawal symptoms are rarely medically dangerous for those in good health, they are extremely uncomfortable, and, in many addicts, they make the alternative, using heroin, more attractive than detoxification. Severe withdrawal is associated with signs of sympathetic nervous system arousal as well as increased pulse, blood pressure, and body temperature. Addicts experience sweating, hair standing on their arms (i.e., gooseflesh—hence the expression ''cold turkey''), muscle twitches (from which the expression ''kicking the habit'' comes), diarrhea, vomiting, insomnia, runny nose, hot and cold flashes, and muscle aches. A host of psychological symptoms accompany the withdrawal distress. After addicts have been detoxified, they may be treated with medications that make it less likely they will use heroin again; these medications that prevent relapse may work by blocking heroin's effects. Medications can also be used to treat underlying psychiatric problems that contributed to the addict's use of drugs.

An alternative approach is Methadone Maintenance, which does not initially aim to stop the addict from using opioids but instead to substitute oral methadone use for heroin abuse. Methadone is a clear liquid, usually dissolved in a flavored drink, that is given once a day and is prescribed by a physician. Used as a way to treat addicts' withdrawal symptoms and drug craving, the prescription of methadone is closely controlled by state and federal regulations.

Opiate Detoxification. The simplest approach to detoxification is to substitute a prescribed opioid for the heroin that the addict is dependent on and then gradually lower the dose of the prescribed opioid. This causes the withdrawal to be less severe, although the withdrawal symptoms may last longer. A typical procedure entails first verifying that addicts are dependent on opioids (by some combination of observed withdrawal, a withdrawal response to naloxone, or evidence of heavy opioid use). The addicts are then given an appro priate dose of methadone, which treats the withdrawal symptoms. They are monitored for overse-dation due to methadone or undermedication of withdrawal symptoms. Intravenous users of street heroin admitted to the hospital usually tolerate well a starting methadone dose of 25 milligrams. The methadone dose is then gradually lowered over the next several days. It is typical to taper a starting methadone dose of 25 milligrams over a period of seven days.

Another approach avoids the difficulties of prescribing an opioid to an addict. It involves using the antihypertensive Clonidine to treat withdrawal symptoms after the addict has stopped using the opiates. Clonidine suppresses many of the physical signs of opiate withdrawal, but it is less effective against many of the more subjective complaints during withdrawal such as lethargy, restlessness, and dysphoria. Clonidine's side effects of low blood pressure, sedation, and blurry vision make it unpleasant to take and unlikely to be abused by addicts. Although clonidine has not been approved by the Food and Drug Administration for opiate detoxification, it is widely used for this purpose and has demonstrated efficacy. It is most effective when used in addicts who are not addicted to large doses of opioids.

Opiate Antagonists. The opiate antagonist Naltrexone is used clinically to accomplish rapid detoxifications and to help detoxified addicts stay off opioids. Naltrexone binds more strongly than heroin to the specific brain receptors to which heroin binds. If, therefore, addicts who are dependent on heroin take a dose of naltrexone, the naltrexone will replace the heroin at the brain receptor and the addicts will feel as if all the heroin has been suddenly taken out of their body. The effect of this rapid reduction in effective heroin (at the receptor) is withdrawal. The withdrawal is usually more severe than that which comes from simply stopping the heroin, but it also has the effect of accomplishing a detoxification more quickly. Thus, a combination treatment of clonidine to suppress the intensity of withdrawal symptoms and naltrexone to accelerate the pace of withdrawal has been used for rapid detoxification.

Naltrexone is primarily used after detoxification to prevent addicts from returning to opioid use. Because naltrexone binds to opioid receptors more tightly than does heroin, opioid addicts on naltrex-one who use heroin will find the heroin effect blocked by naltrexone. Addicts maintained on naltrexone who use heroin will only be wasting their money. One effect of naltrexone is thus to extinguish the conditioned response to heroin injection. Naltrexone is prescribed in the form of a pill that can be given as infrequently as three times a week. It has few side effects in the majority of patients who take it, and, contrary to some rumors, it does not suppress other ''natural highs.''

Opioid Maintenance. Methadone is the most common opioid used for the maintenance treatment of opioid addicts. Methadone satiates the heroin user's craving for heroin in order to prevent heroin withdrawal. The more important therapeutic effect of methadone, however, is tolerance to it. Addicts maintained on a stable dose of methadone do not get high from each dose because they are tolerant to it. This tolerance extends to heroin, and methadone-maintained addicts who use heroin experience a lesser effect because of the tolerance. Tolerance accounts for the fact that methadone-maintained addicts can take methadone doses that would cause a naive (i.e., first-time) drug user to die of an overdose. Generally, methadone-main-tained addicts do not appear to be either intoxicated or in withdrawal. Tolerance is admittedly incomplete, and methadonemaintained addicts have some opioid side effects that they do not become tolerant to—for example, constipation, excessive sweating, and decreased libido. There is no known medical danger associated with methadone maintenance, however.

Methadone is dispensed as part of licensed programs, usually on a daily basis. It is generally well received by addicts, and the risk of incurring withdrawal symptoms if methadone treatment is interrupted provides a strong incentive for addicts to keep appointments. The ritual of daily clinic attendance has the additional therapeutic benefit of beginning to impose structure on the chaotic lives of most opiate addicts. Methadone treatment is often augmented with medical, financial, and psychological support services to address the many needs of opioid addicts.

Despite the philosophical debates about the appropriateness of using methadone, there is a large body of evidence indicating that methadone-main-tained addicts show decreases in heroin use, crimes committed, and psychological symptoms. The major drawbacks to methadone maintenance include the great difficulty of achieving detoxification from methadone, the methadone side effects, and the possibility of increased use of other illicit drugs such as cocaine.

An opiate addict initially coming in for treatment will usually be put through detoxification and possibly put on naltrexone maintenance. Addicts with intact family supports, good jobs, or strong motivation are more likely to benefit from naltrex-one maintenance than those who are more impaired. Younger addicts and adolescents are urged to try nonmethadone approaches, so as to avoid developing a methadone addiction. Methadone maintenance is usually reserved for patients who have failed at previous detoxifications. An exception is made for pregnant women, in whom metha-done maintenance is the treatment of choice, with detoxification of the infant from methadone accomplished after birth. Opiate detoxification is risky in pregnant women because of the adverse effects on fetal development in the first and second trimesters, and the risk of miscarriage.

Other nonmethadone medications for maintenance treatment of opioid dependence have not yet been widely used. Buprenorphine is a partial opi-oid agonist medication that has the advantages of being safe, even at higher doses, and being associated with less severe withdrawal symptoms than methadone after discontinuation. Another medication recently approved for treating opioid dependence is LAAM (levo-alpha-acetylmethadol). LAAM is broken down in the body to very long-acting active metabolites, and therefore it can be prescribed as infrequently as three times a week.

Detoxification and Weight Loss

Detoxification and Weight Loss

Detoxification is something that is very important to the body, but it is something that isn't understood well. Centuries ago, health masters in the East understood the importance of balancing and detoxifying the body. It's something that Western medicine is only beginning to understand.

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