Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

152 III. SUBSTANCES OF ABUSEMaintenanceAfter detoxification, relapse prevention must be actively addressed with whatevertreatment interventions are available.Unfortunately, a large percentage of addicts seem unable to tolerate acutewithdrawal, to succeed at controlled detoxification, or to remain drug free.Methadone maintenance may then become the treatment of choice. Administeredon a once-a-day schedule, methadone in appropriate doses blocks opioidwithdrawal, thus reducing compulsive drug-seeking behavior and use. The individualmay then focus energy and attention on more productive behaviors.Indications for the use of methadone maintenance include (1) a history ofchronic, high-dose opioid abuse; (2) repeated failures at abstinence; (3) historyof prior successful methadone maintenance; (4) history of drug-related criminalconvictions or incarcerations; (5) pregnancy, especially first and third trimesters;and (6) HIV seropositivity.Relative contraindications to methadone maintenance include (1) age lessthan 16 years, (2) the expectation of incarceration within 30–45 days, and (3)history of abuse of methadone maintenance, including diversion of methadoneto “the street” and failure to cease illicit use despite adequate doses.The administration of methadone, as noted earlier, is heavily regulated byFederal and state governments. Specific requirements must be met by individualsand clinics offering this service. Generally, after the individual’s history andphysical condition are assessed, methadone dosing begins according to the protocolpreviously described. A period of 4–10 days may be required to stabilizethe patient at an appropriate dose. When stabilization has occurred, the individual’sillicit drug use should cease, as evidenced by regular, monitored urinalysisshowing only methadone. Methadone maintenance programs that maintainan overall average dose of 60–100 mg a day yield consistently better resultsin decreasing illicit opioid use. Doses in excess of 120 mg a day are seldomneeded (Gerstein, 1990). A pitfall here is that individuals may supplementtheir maintenance dose with “black market” methadone. Urinalyses will not behelpful in detecting this behavior, since quantification techniques are not generallyemployed. 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 theoral 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 whichcan precipitate withdrawal symptoms by reducing methadone plasma levels.Concealed regular use of other opiates in addition to methadone will result inthe user’s asking for more methadone, because the development of tolerancehas outpaced current stable dosing. Abusive use of alcohol and/or benzodiazepineswith methadone maintenance will also cause individuals to request