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

650 V. TREATMENTS FOR ADDICTIONSfor drug dependence (Rounsaville & Kosten, 2000). Barriers to access to methadonemaintenance include both limited patient and community acceptance ofmethadone, and regulatory restrictions and the lack of availability in manyareas of the country. Development of alternative maintenance agents, andespecially agents that can be more readily administered with reduced clinicattendance and outside of traditional methadone maintenance settings, mayaddress some of the problems associated with limited access to treatment.Buprenorphine, a partial mu agonist and kappa antagonist, represents apromising alternative to methadone and was recently approved by the FDA.Because of its unique pharmacological properties, there may be a number ofadvantages to its use, compared to either methadone or levo-alpha-acetylmethadol (LAAM), as a maintenance agent for the treatment of opioiddependence settings. Ceiling effects at higher buprenorphine doses result in alower risk of overdose compared with methadone, and buprenorphine may alsohave a reduced abuse liability in opiate-dependent individuals (thus, less likelihoodfor diversion), because its use may precipitate withdrawal symptoms(Strain, Preston, Liebson, & Bigelow, 1995; Walsh, Preston, Bigelow, & Stitzer,1995). Withdrawal symptoms following abrupt discontinuation of buprenorphineare also usually relatively mild (Cowan & Lewis, 1995; Fudala, Jaffe, Dax,& Johnson, 1990). Results of random assignment, double-blind clinical trialsgenerally support the safety and dose-dependent efficacy of buprenorphinemaintenance (Fudala et al., 2003; Ling, Wesson, Charavastra, & Klett, 1996;Schottenfeld, Pakes, Oliveto, Ziedonis, & Kosten, 1997).Because buprenorphine have been made available only recently, very fewstudies have been done to identify predictors of patient response to methadoneversus buprenorphine, or the minimal and optimal intensity of behavioral treatmentto be administered in conjunction with these maintenance agents. However,it is likely that the same principles as those found in the methadone literatureregarding use of behavioral therapies to enhance outcome with theseagents as will emerge over time.Naltrexone–Agonist TreatmentOpioid antagonist treatment (naltrexone) offers many potential advantagesover methadone maintenance: It is nonaddicting and can be prescribed withoutconcerns about diversion, it has a benign side-effect profile, and it may be lesscostly, in terms of demands on professionals and patients’ time, than the dailyor near-daily clinic visits required for methadone maintenance (Rounsaville,1995). Most important are behavioral aspects of the treatment, because unreinforcedopiate use allows extinction of relationships between cues and druguse. While naltrexone treatment is likely to be attractive only to a minority ofopioid addicts (Cornish et al., 1997), naltrexone’s unique properties make it animportant alternative to methadone maintenance.