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

596 V. TREATMENTS FOR ADDICTIONShave abuse liability, and produce physiological and psychological dependence.Physiological dependence occurs with longer term (greater than 30 days) use,requiring tapering of the drug, and tolerance that develops with prolonged usecan lead to escalating dosages. Interestingly, severity of the withdrawal syndromedoes not correlate significantly with difficulty in benzodiazepine taper(Rickels, De Martinis, Rynn, & Mandos, 1999). Personality psychopathologyappears to contribute to withdrawal severity and lack of successful taper. Furthermore,a study examining benzodiazepine taper in a sample of sedative/hypnotic-dependent patients reported that those with personality pathologywere more likely to drop out of the taper in the early stage prior to significantdose reductions (Rickels, Schweizer, Case, & Garcia-Espana, 1988). In a 3-yearfollow-up study of outcomes, it was determined that those who participated in ataper leading to a 50% reduction in daily benzodiazepine use had a 39% rate ofbeing benzodiazepine-free. Eighty-six percent of those who refused a taper continuedbenzodiazepine use at 3 years, and those who successfully ended benzodiazepineuse reported significantly lower levels of anxiety compared to patientswho continued to use benzodiazepines (Rickels, Case, Schweizer, Garcia-Espana, & Fridman, 1991).Benzodiazepine taper can be undertaken rapidly in an inpatient setting orslowly on an outpatient basis. The taper of a benzodiazepine is usually undertakenwith the substitution of another benzodiazepine, particularly if thepatient is dependent on a drug with a short half-life. These drugs can be taperedby converting the daily reported use of a benzodiazepine reduced by 50% to theequivalent dose of chlordiazepoxide, clonazepam, or, in cases where there isconcern for hepatic disease and a decreased ability to metabolize the benzodiazepineand its active metabolites, or concern about inability of the patient totake oral medications, lorazepam. The total daily dose required to stabilize thepatient on the first day of the taper can be reduced by up to 10–20% daily, leadingto detoxification over several days.OPIOID PHARMACOTHERAPIESTreatment of OverdoseOpioid overdose is a medical emergency and can be life threatening when complicationsof coma and/or respiratory arrest occur. Naloxone is an injectabledrug that rapidly reverses effects of opioid overdose by displacing the opioidfrom receptors in the brain. Naloxone may be administered intravenously or, inthose without venous access, by subcutaneous injection. A dosage of 0.4–0.8mg should reverse most opioid overdoses. In dependent patients, lower doses(0.1–0.2 mg) may be sufficient; furthermore, it is not advisable to precipitatewithdrawal in these patients. Therefore, in these cases, treatment should beginwith lower naloxone doses, with the dosage increased as clinically indicated.