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

598 V. TREATMENTS FOR ADDICTIONSKhan, Mumford, Rogers, and Beckford (1997) reported that lofexidine, analpha 2adrenergic agonist that produces less hypotension than clonidine, can bea useful adjunctive medication during methadone detoxification. Lofexidinewas equal to clonidine in reducing symptoms of opioid withdrawal, andside effects of hypotension and lethargy were reported by substantially fewerpatients in the lofexidine group. Clonidine can also be used as an adjunctivemedication to assist with emerging withdrawal symptoms during detoxification,but medical complications related to hypotension and sedation can limit tolerancefor this drug. Methadone detoxification should be completed within 3weeks (Van den Brink, Goppel, & van Ree, 2003). Detoxification protocols aresummarized in Figure 26.1.Opioid detoxification can also be undertaken with buprenorphine, anopioid partial agonist (Kosten & Kleber, 1988; Lewis, 1985). In one study, heroinaddicts and methadone-maintained patients were converted to buprenorphinefor a month of stabilization at once-daily doses ranging from 2 to 8 mgsublingually. Following this period, buprenorphine was abruptly stopped, andthe patient was given a high dose of intravenous naloxone (35 mg) to precipitatewithdrawal from the buprenorphine (Kosten et al., 1989). This withdrawalsyndrome was relatively mild and treated with clonidine, if needed. Followingprecipitated withdrawal, it was possible for the patient to be started onnaltrexone the same day. Additional studies in which the sublingual formulationsof buprenorphine are used for detoxification are ongoing at this time.Buprenorphine can also be combined with clonidine and naltrexone for ahighly successful rapid detoxification that is medically safe and preferred bypatients to the alternative of clonidine alone or clonidine plus naltrexone inheroin- or methadone-stabilized patients. The details for such a buprenorphineprotocol are also provided in Figure 26.1.Another method of opiate detoxification has been termed “rapid” or“ultrarapid” detoxification in which withdrawal is precipitated by administrationof either naloxone or naltrexone, with heavy sedation or anesthesia to easewithdrawal symptoms. This procedure produces more severe withdrawal thanstandard opioid detoxification procedures, but the hypothesis is that the use ofan opioid antagonist to induce withdrawal will curtail the duration of the withdrawalsyndrome. This procedure has been associated with severe adverseevents, including complications of anesthesia, severe withdrawal symptomslasting for several days following the procedure, and, rarely, death (Badenoch,2002; Cucchia, Monat, Spagnoli, Ferrero, & Gertschy, 1998; O’Connor &Kosten, 1998; Rabinowitz, Cohen, & Atias, 2002; Scherbaum et al., 1998).Furthermore, this procedure has not been associated with better long-term outcomesin terms of relapse to opiate dependence, calling into question theexpense and risk of the procedure relative to other procedures for opioidwithdrawal (Cucchia et al., 1998; Lawental, 2000; Rabinowitz et al., 2002;Scherbaum et al., 1998).