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

646 V. TREATMENTS FOR ADDICTIONS(Volpicelli et al., 1997), which underscores the importance of delivering naltrexonein conjunction with an effective behavioral approach that addresses compliance.Thus, it is not surprising that naltrexone’s effects have been found to differsomewhat depending on the nature of the behavioral treatment with which it isdelivered. For example, in the O’Malley and colleagues (1992) study, highestrates of abstinence were found when the patient received naltrexone plus a supportiveclinical management psychotherapy condition that encouraged completeabstinence from alcohol and other substances. However, for patients whodrank, the combination of a cognitive-behavioral coping skills approach andnaltrexone was superior in terms of rates of relapse and drinks per occasion.Evaluation of naltrexone’s effectiveness in combination with acamprosate,another promising medication, and with brief versus more intensive behavioraltreatment that should shed light on important data regarding the types ofpatients who respond to lower versus higher intensity behavioral approacheswith naltrexone, is ongoing (COMBINE Study Research Group, 2003).TREATMENT OF OPIOID DEPENDENCEThe inception of methadone maintenance treatment revolutionized the treatmentof opioid addiction, because it displayed the previously unseen ability tokeep addicts in treatment and to reduce their illicit opioid use, outcomes withwhich nonpharmacological treatments had fared comparatively poorly. Beyondits ability to retain opioid addicts in treatment and help control opioid use,methadone maintenance also reduces the risk of HIV infection and other medicalcomplications through reducing intravenous drug use (Ball & Ross, 1991),and provides the opportunity to evaluate and treat concurrent disorders, includingmedical problems and family and psychiatric problems. The bulk of thelarge body of literature on the effectiveness of methadone maintenance pointsto its success in retaining opioid addicts in treatment and reducing their illicitopioid use and illegal activity (Ball & Ross, 1991). Methadone maintenancetreatment, especially when provided at adequate doses and combined with drugcounseling, substantially decreases illicit opioid use, injection drug use, criminalactivity, and morbidity and mortality risk (O’Brien, 1997). However, there is agreat deal of variability in the success across different methadone maintenanceprograms, which appears to be largely associated with both variability in deliveryof adequate dosing of methadone and in provision and quality of psychosocialservices (Ball & Ross, 1991).There remain, however, several problems with methadone maintenance,including illicit diversion of take-home methadone doses, difficulties withdetoxification from methadone maintenance to a drug-free state, and the concurrentuse of other substances, particularly alcohol and cocaine, among