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

28. Matching and Differential Therapies 639DetoxificationFor those classes of substances that produce substantial physical withdrawalsyndromes (e.g., alcohol, opioids, sedatives/hypnotics), medications are oftenneeded to reduce or control the often-dangerous symptoms associated withwithdrawal. Benzodiazepines are often used to manage symptoms of alcoholwithdrawal. Agents such as methadone, clonidine, naltrexone, and buprenorphineare typically used for the management of opioid withdrawal. Typically,the role of behavioral treatments during detoxification is typically extremelylimited due to the level of discomfort, agitation, and confusion the patient mayexperience. However, studies have suggested the effectiveness of behavioralstrategies in increasing retention and abstinence in the course of longer termoutpatient detoxification protocols (Bickel, Amass, Higgins, Badger, & Esch,1997).Stabilization and MaintenanceA widely-used example of the use of a medication for long-term stabilization ofdrug users is methadone maintenance for opioid dependence, a treatment strategythat involves the daily administration of a long-acting opioid (methadone)as a substitute for the illicit use of short-acting opioids (typically heroin). Methadonemaintenance permits the patient to function normally, without experiencingwithdrawal symptoms, craving, or side effects. The large body ofresearch on methadone maintenance confirms its importance in fostering treatmentretention, providing the opportunity to evaluate and treat other problemsand disorders that often coexist with opioid dependence (e.g., medical, legal,and occupational problems), reducing the risk of HIV infection and other complicationsthrough reducing intravenous drug use, and providing a level of stabilizationthat permits the inception of psychotherapy and other aspects of treatment.Antagonist and OtherBehaviorally Oriented PharmacotherapiesA more recent pharmacological strategy is the use of antagonist treatment, thatis, the use of medications that block the effects of specific drugs. An example ofthis approach is naltrexone, an effective, long-acting opioid antagonist. Naltrexoneis nonaddicting, does not have the reinforcing properties of opioids, hasfew side effects and, most important, effectively blocks the effects of opioids.Therefore, naltrexone treatment represents a potent behavioral strategy: Becauseopioid ingestion is not reinforced while the patient is taking naltrexone,unreinforced opioid use allows extinction of relationships between conditioneddrug cues and drug use. For example, a naltrexone-maintained patient, antici-