Multiple family therapy and naltrexone in the treatment of opiate dependence

Multi-Family Therapy with a Reflecting Team: A Preliminary Study on Efficacy among Opiate Addicts in Methadone Maintenance Treatment

In this study, we evaluate the efficacy of multi-family therapy at reducing the addiction severity and at improving the psychological and family dynamics of opiate addicts receiving methadone treatment at a public treatment center. The study compares multi-family therapy with a reflecting team (MFT-RT) and a standard treatment following a methadone maintenance treatment program. The results show that multi-family therapy with a reflecting team effectively reduces the addiction severity in several of the areas evaluated and noted that this effect is superior to standard treatment. The psychotherapy patients showed improvement in the areas of employment and social support; their drug use diminished and their psychiatric condition improved. At the same time, they needed a lower daily dose of methadone. In addition, the group undergoing standard treatment showed a noteworthy deterioration in their medical condition. Both groups showed a significant increase in their alcohol use. When applied to family treatments, the systemic-constructivist approach by the reflecting team offers combined techniques that can help improve care for the families of patients with addiction problems.

Evaluating Multiple Family Groups to Address the Behavioral Difficulties of Urban Children

This article describes the use and evaluation of multiple family groups within a minority, inner-city clinic sample of children and families. Multiple family groups are described in terms of their application to this clinical population. This study used a single group pretest-posttest design to evaluate the effectiveness of an 8-weekmultiplefamily group meant to address the behavioral difficulties of 32 children. Change between preassessment and postassessment was measured using the Conners Parent Rating Scale, which consists of six subscales: anxiety, conduct, hyperactivity, impulsivity, learning, and somatization. Statistically significant improvements were observed on the conduct, hyperactivity, impulsivity, and learning subscales over the intervention period. These results point to the need for further controlled studies of the effectiveness of multiple family groups, particularly with inner-city children andfamilies.

Employment-based reinforcement of adherence to oral naltrexone in unemployed injection drug users: 12-month outcomes

Oral naltrexone could be a promising relapse-prevention pharmacotherapy for recently detoxified opioid-dependent patients; however, interventions are often needed to promote adherence with this treatment approach. We recently conducted a study to evaluate a 26-week employment-based reinforcement intervention of oral naltrexone in unemployed injection drug users (Dunn et al., 2013). Participants were randomly assigned into a contingency (n = 35) group required to ingest naltrexone under staff observation to gain entry into a therapeutic workplace or a prescription (n = 32) group given a take-home supply of oral naltrexone and access to the workplace without observed ingestion. Monthly urine samples were collected and analyzed for evidence for naltrexone adherence, opioid use, and cocaine use. As previously reported, contingency participants provided significantly more naltrexone-positive urine samples than prescription participants during the 26-week intervention period. The goal of this current study is to report the 12-month outcomes, which occurred 6 months after the intervention ended. Results at the 12-month visit showed no between-groups differences in naltrexone-positive, opioid-negative, or cocaine-negative urine samples and no participant self-reported using naltrexone at the follow-up visit. These results show that even after a period of successfully reinforced oral naltrexone adherence, longer-term naltrexone use is unlikely to be maintained after reinforcement contingencies are discontinued. (PsycINFO Database Record

The use of naltrexone, an opiate antagonist, in the treatment of opiate addiction

Objective: The objective of this article is to review the use of the opiate antagonist naltrexone as an alternative to opiate agonist maintenance in the treatment of opiate addiction.

Method: An extensive literature search, via Medline, Biosis, Psycinfo and other databases was carried out.

Results: Naltrexone has been used in the treatment of opiate addicts in a variety of settings. A number of methods of induction onto naltrexone of recently abstinent addicts have been used in different settings. Naltrexone has had a wide range of outcome success with different populations and associated treatment regimes.

Conclusions: The benefits of naltrexone can be compared with alternatives such as methadone maintenance and therapeutic communities. Naltrexone can be made more effective in the general population of opiate addicts with the use of adjunctive therapies.

Open label trial of naltrexone implants: measuring blood serum levels of naltrexone

The usefulness of oral naltrexone has been limited by compliance. Sub-cutaneous implants would seem to offer a solution to this problem and improve long-term outcomes. The aim of the present study was to compare levels of blood serum naltrexone of patients who had received a naltrexone implant after detoxification to a number of dependent variables of interest. These dependent variables included drug use including urine screens of each patient, any adverse response to the implant, subjective evaluation of self-esteem, quality of relationships, and changes in social functioning. Sixty six patients received an implant and were surveyed; urine and blood samples were taken at about 1, 3, and 6 months after implantation. Naltrexone levels were on average above 1 ng/mL at 6 months after insertion and patients showed significant improvements on all dependent variables. The preliminary evidence indicates that implants can improve compliance rates and outcomes.

Prediction of abstinence in opioid-dependent patients

OBJECTIVES

: Opioid detoxification with subsequent naltrexone is found to be an effective method as the first step in an abstinence-oriented approach. The aim of this study is to investigate the predictive value of variables for abstinence in opioid-dependent patients.

METHODS

: Opioid-dependent patients were followed up to 1 month after detoxification. Predictor variables were assessed at baseline, during detoxification, and at discharge. Primary outcome was abstinence assessed by analyzing urine samples and self-reports. Logistic regression was used to identify predictors of abstinence.

RESULTS

: Of 272 participants, 211 could be rated as abstinent (59.2%) or nonabstinent (40.8%) at 1 month follow-up. Significant baseline predictors were severity score of justice/police (ASI) and physical quality of life (SF-36); discharge predictors were general quality of health (SF-36) and sleeping problems (SCL-90); change in sleeping problems (SCL-90) during detoxification was also a predictor. The explained variance of these predictors was very low and clinical significance was limited.

CONCLUSIONS

: Considering the results it seems not possible to predict who will be abstinent or not 1 month after detoxification. Because rapid detoxification is found to be an effective detoxification method in selected patients, it seems warranted to recommend that patients with similar characteristics (ie, patients motivated for an abstinence-based treatment and low non-drug-related severity scores on the ASI) should be regarded as eligible for rapid detoxification.

Selective review and commentary on emerging pharmacotherapies for opioid addiction

Pharmacotherapies for opioid addiction under active development in the US include lofexidine (primarily for managing withdrawal symptoms) and Probuphine®, a distinctive mode of delivering buprenorphine for six months, thus relieving patients, clinicians, and regulatory personnel from most concerns about diversion, misuse, and unintended exposure in children. In addition, two recently approved formulations of previously proven medications are in early phases of implementation. The sublingual film form of buprenorphine + naloxone (Suboxone®) provides a less divertible, more quickly administered, more child-proof version than the buprenorphine + naloxone sublingual tablet. The injectable depot form of naltrexone (Vivitrol®) ensures consistent opioid receptor blockade for one month between administrations, removing concerns about medication compliance. The clinical implications of these developments have attracted increasing attention from clinicians and policymakers in the US and around the world, especially given that human immunodeficiency virus/acquired immunodeficiency syndrome and other infectious diseases are recognized as companions to opioid addiction, commanding more efforts to reduce opioid addiction. While research and practice improvement efforts continue, reluctance to adopt new medications and procedures can be expected, especially considerations in the regulatory process and in the course of implementation. Best practices and improved outcomes will ultimately emerge from continued development efforts that reflect input from many quarters.

Oral naltrexone maintenance treatment for opioid dependence

BACKGROUND

Research on clinical application of oral naltrexone agrees on several things. From a pharmacological perspective, naltrexone works. From an applied perspective, the medication compliance and the retention rates are poor.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment versus placebo or other treatments in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched: Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library issue 6 2010), PubMed (1973- June 2010), CINAHL (1982- June 2010). We inspected reference lists of relevant articles and contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups.

SELECTION CRITERIA

All randomised controlled clinical trials which focus on the use of naltrexone maintenance treatment versus placebo, or other treatments to reach sustained abstinence from opiate drugs

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed studies for inclusion and extracted data. One reviewer carried out the qualitative assessments of the methodology of eligible studies using validated checklists.

MAIN RESULTS

Thirteen studies, 1158 participants, met the criteria for inclusion in this review.Comparing naltrexone versus placebo or no pharmacological treatments, no statistically significant difference were noted for all the primary outcomes considered. The only outcome statistically significant in favour of naltrexone is re incarceration, RR 0.47 (95%CI 0.26-0.84), but results come only from two studies. Considering only studies were patients were forced to adherence a statistical significant difference in favour of naltrexone was found for retention and abstinence, RR 2.93 (95%CI 1.66-5.18).Comparing naltrexone versus psychotherapy, in the two considered outcomes, no statistically significant difference was found in the single study considered.Naltrexone was not superior to benzodiazepines and to buprenorphine for retention and abstinence and side effects. Results come from single studies.

AUTHORS' CONCLUSIONS

The findings of this review suggest that oral naltrexone did not perform better than treatment with placebo or no pharmacological agent with respect to the number of participants re-incarcerated during the study period. If oral naltrexone is compared with other pharmacological treatments such as benzodiazepine and buprenorphine, no statistically significant difference was found. The percentage of people retained in treatment in the included studies is however low (28%). The conclusion of this review is that the studies conducted have not allowed an adequate evaluation of oral naltrexone treatment in the field of opioid dependence. Consequently, maintenance therapy with naltrexone cannot yet be considered a treatment which has been scientifically proved to be superior to other kinds of treatment.

Oral naltrexone maintenance treatment for opioid dependence

BACKGROUND

Research on the clinical application of oral naltrexone agrees on several things. From a pharmacological perspective, naltrexone works. From an applied perspective, however, the medication compliance and the retention rates are very poor.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment versus placebo or other treatments in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library issue 6 2010), PubMed (1973- June 2010), CINAHL (1982- June 2010). We inspected reference lists of relevant articles and we contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups.

SELECTION CRITERIA

All randomised and controlled clinical trials which focus on the use of naltrexone maintenance treatment versus placebo, or other treatments to reach sustained abstinence from opiate drugs

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed studies for inclusion and extracted data. One reviewer carried out the qualitative assessments of the methodology of eligible studies using validated checklists.

MAIN RESULTS

Thirteen studies, 1158 participants, met the criteria for inclusion in this review.Comparing naltrexone versus placebo or no pharmacological treatments, no statistically significant difference were noted for all the primary outcomes considered. The only outcome statistically significant in favour of naltrexone is re incarceration, RR 0.47 (95%CI 0.26-0.84), but results come only from two studies.Comparing naltrexone versus psychotherapy, in the two considered outcomes, no statistically significant difference was found in the single study considered.Naltrexone was not superior to benzodiazepines and to buprenorphine for retention and abstinence and side effects. Results come from single studies.

AUTHORS' CONCLUSIONS

The findings of this review suggest that oral naltrexone did not perform better than treatment with placebo or no pharmacological agent with respect to the number of participants re-incarcerated during the study period. If oral naltrexone is compared with other pharmacological treatments such as benzodiazepine and buprenorphine, no statistically significant difference was found. The percentage of people retained in treatment in the included studies is however low (28%). The conclusion of this review is that the studies conducted have not allowed an adequate evaluation of oral naltrexone treatment in the field of opioid dependence. Consequently, maintenance therapy with naltrexone cannot yet be considered a treatment which has been scientifically proved to be superior to other kinds of treatment.

Sustained-release naltrexone: novel treatment for opioid dependence

The devastating costs of opioid abuse and dependence underscore the need for effective treatments for these disorders. At present, several different maintenance medications exist for treating opioid dependence, including methadone, buprenorphine and naltrexone. Of these, naltrexone is the only one that possesses no opioid agonist effects. Instead, naltrexone occupies opioid receptors and prevents or reverses the effects produced by opioid agonists. Despite its clear pharmacologic effectiveness, its clinical effectiveness in treating opioid dependence has been disappointing, primarily due to non-compliance with taking the medication. However, the recent availability of sustained-release formulations of naltrexone has renewed interest in this medication. The present paper describes the development of sustained-release naltrexone formulations and discusses the clinical issues associated with their use in treating opioid dependence.

Oral naltrexone maintenance treatment for opioid dependence

BACKGROUND

Research on the clinical application of oral naltrexone agrees on several things. From a pharmacological perspective, naltrexone works. From an applied perspective, however, this medication is not used since the medication compliance and the retention rates are very poor.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment versus placebo or other treatments in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group Register of Trials (January 2005), Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library Issue 1, 2005), MEDLINE (1973-first year of naltrexone use in humans- January 2005), EMBASE (1974- January 2005), PsycINFO (OVID-January 1985 to January 2004). We inspected reference lists of relevant articles and we contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups.

SELECTION CRITERIA

All randomised and controlled clinical trials which focus on the use of naltrexone maintenance treatment versus placebo, or other treatments to reach sustained abstinence from opiate drugs

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed studies for inclusion and extracted data. One reviewer carried out the qualitative assessments of the methodology of eligible studies using validated checklists.

MAIN RESULTS

Ten studies, 696 participants, met the criteria for inclusion in this review. Only two studies described an adequate allocation concealment. The results show that naltrexone maintenance therapy alone or associated with psychosocial therapy is more efficacious that placebo alone or associated with psychosocial therapy in limiting the use of heroin during the treatment (RR 0,72 95% confidence interval 0.58 to 0.90). If we consider only the studies comparing naltrexone with placebo, the difference do not reach the statistical significancy, RR 0.79 (95%CI 0.59 to 1.06). With respect to the number of participants re incarcerated during the study period, the naltrexone associated with psychosocial therapy is more effective than the psychosocial treatment alone; RR 0.50 (95%CI 0.27 to 0.91). No statistically significant benefit was shown in terms of retention in treatment, side effects or relapse results at follow-up for any of the considered comparisons.

AUTHORS' CONCLUSIONS

Unfortunately the studies did not provide an objective evaluation of naltrexone treatment in the field of opioid dependence. The conclusions are also limited due to the heterogeneity of the trials both in the interventions and in the assessment of outcomes.

Reducing hospital presentations for opioid overdose in patients treated with sustained release naltrexone implants

BACKGROUND

Non-fatal overdoses represent a significant morbidity for regular heroin users. Naltrexone is an opioid antagonist capable of blocking the effects of heroin, thereby preventing accidental overdose. However, treatment with oral naltrexone is often associated with non-compliance. An alternative is the use of a sustained release preparation of naltrexone. The aim of this study was to assess the change in number of opioid and other drug overdoses in a large cohort of heroin dependent persons (n=361; 218 males) before and after treatment with a sustained release naltrexone implant. A sub-group of this cohort (n=146; 83 males) had previously received treatment with oral naltrexone, which also allowed a comparison of overdoses pre- and post-oral and also post-implant treatments.

METHOD

We used a pre-post design, with data prospectively collected via the West Australian Health Services Research Linked Database, and the Emergency Department Information System. Participants were treated under the Australian Therapeutic Goods Administration's special access guidelines.

RESULTS

Most (336, 93%) of the cohort was in one or both databases. We identified 21 opioid overdoses involving 20 persons in the 6 months pre-treatment that required emergency department presentation or hospital admission: none were observed in the 6 months post-treatment. This is consistent with the existing pharmacokinetic data on this implant, which indicates maintenance of blood naltrexone levels at or above 2 ng/ml for approximately 6 months. A reduced number of opioid overdoses were also observed 7-12 months post-implant. The study found a significant increase in sedative "overdoses", some of which occurred in the 10 days following implant treatment and were likely associated with opioid withdrawal and/or implant treatment. For those previously treated with oral naltrexone, more opioid overdoses occurred in both the 6-months prior to and after oral compared to the 6-months post-implant treatment.

CONCLUSIONS

The findings support the clinical efficacy of this sustained release naltrexone implant in preventing opioid overdose. However, given the high prevalence of poly-substance use among dependent heroin users, programs offering this type of treatment should also focus on preventing, detecting and managing poly-substance use.

Naltrexone for heroin dependence treatment in St. Petersburg, Russia

Naltrexone may be more effective for treating opioid (heroin) dependence in Russia than in the U.S. because patients are mostly young and living with their parents, who can control medication compliance. In this pilot study we randomized 52 consenting patients who completed detoxification in St. Petersburg to a double blind, 6-month course of biweekly drug counseling and naltrexone, or counseling and placebo naltrexone. Significant differences in retention and relapse favoring naltrexone were seen beginning at 1 month and continuing throughout the study. At the end of 6 months, 12 of the 27 naltrexone patients (44.4%) remained in treatment and had not relapsed as compared to 4 of 25 placebo patients (16%; p<0.05). Since heroin dependence is the main way HIV is being spread in Russia, naltrexone is likely to improve treatment outcome and help reduce the spread of HIV if it can be made more widely available.

Achieving long-term continuous blood naltrexone and 6-beta-naltrexol coverage following sequential naltrexone implants

The aim of this study was to assess blood free naltrexone and 6-beta-naltrexol levels with time following treatment with sequential sustained-release naltrexone preparations. Data were collected from blood samples analysed independently for naltrexone and 6-beta-naltrexol and from clinical record review at a community heroin treatment clinic in Perth, Western Australia. Five patients received sequential 3.4 g (3.49+/-0.01 g and 3.36+/-0.05 g, respectively) naltrexone implants. The second implant was received on average within 131.2+/-15.67 days of the first implant. The mean length of follow-up was 307.2+/-18.28 days of the first implant. Blood naltrexone levels have the potential to remain above 2 and 1 ng/ml for a total of 390 and 524 days, respectively, and blood 6-beta-naltrexol was maintained above 10 ng/ml for a total of 222 days following insertion of these implants. No patient relapsed to dependent heroin use during the implant coverage period while blood naltrexone concentrations were above 2 ng/ml. Results indicate that blood naltrexone and 6-beta-naltrexol levels can be maintained above therapeutic levels for prolonged periods following use of sequential 3.4 g naltrexone implants. These extended periods of coverage will offer significant benefits for managing the heroin-dependent patient.

A pilot study to assess the impact of naltrexone implant on accidental opiate overdose in 'high-risk' adolescent heroin users

Morbidity and mortality rates for regular heroin users are much greater than those observed in the general population. In 'high-risk' heroin users implantable naltrexone has been used under Commonwealth Therapeutic Goods Administration Compassionate guidelines in Western Australia since August 2000. This pilot study compared the frequency of accidental opiate overdose and other morbidity resulting in hospital presentations in eight 'high-risk' dependent heroin using adolescents pre- and post-naltrexone implant treatment. We reviewed the hospital medical records retrospectively for t he participants across the four public hospitals in Perth. The review period was September 1999-October 2002. The eight adolescents (aged 15-19 years) initially underwent naltrexone implant treatment between September 2000 and September 2001. The data indicated a dramatic reduction in opiate overdose post-implantable naltrexone treatment, with a smaller reduction in opiate overdose during oral naltrexone treatment compared to the pre-oral/implant period. Implant treatment in the high-risk heroin user may provide an important prophylaxis against mortality associated with accidental opiate overdose. These encouraging findings now require validation using a larger cohort over an extended period

Behavioral family counseling and naltrexone for male opioid-dependent patients

Men (N = 124) entering treatment for opioid dependence who were living with a family member were randomly assigned to one of two 24-week treatments: (a) behavioral family counseling (BFC) plus individual treatment (patients had both individual and family sessions and took naltrexone daily in presence of family member) or (b) individual-based treatment only (IBT; patients were given naltrexone and were asked in counseling sessions about their compliance, but there was no family involvement). BFC patients, compared with their IBT counterparts, ingested more doses of naltrexone, attended more scheduled treatment sessions, had more days abstinent from opioids and other drugs during treatment and during the year after treatment, and had fewer drug-related, legal, and family problems at 1-year follow-up.

Behavioral naltrexone therapy: an integrated treatment for opiate dependence

Treatment of opiate dependence with naltrexone has been limited by poor compliance. Behavioral Naltrexone Therapy (BNT) was developed to promote adherence to naltrexone and lifestyle changes supportive of abstinence, by incorporating components from empirically validated treatments, including Network Therapy with a significant other to monitor medication compliance, the Community Reinforcement Approach, and voucher incentives. An overview is presented of the BNT treatment manual. In an uncontrolled Stage I trial (N = 47), 19% completed the 6-month course of treatment. Retention was especially poor in the subsample of patients who were using methadone at baseline (N = 18; 39% completed 1 month, none completed 6 months), and more encouraging among heroin-dependent patients (N = 29; 65% completed 1 month, 31% completed 6 months). Thus, attrition continues to be a serious problem for naltrexone maintenance, although further efforts to develop interventions such as BNT are warranted.

Characteristics, retention and readmissions of opioid-dependent clients treated with oral naltrexone

The aims of this study were to examine the retention rates of opioid-dependent clients treated with oral naltrexone and identify factors that influence retention in treatment of 981 opioid-dependent clients at a public out-patient clinic in Perth, Western Australia. The average retention period for all clients was 9.0 weeks. The factors associated with longer retention were being employed and referral source. Clients who were employed stayed significantly longer in treatment than unemployed clients. Clients referred from a private clinic were retained in treatment significantly longer than those referred from other sources (X = 10.3 vs. 5.9 weeks). While the majority (80.8%) had one admission to naltrexone treatment, 19.2% presented for readmission, some on three or more occasions in the study period. The median period between the end of the first episode of treatment and commencement of the second was 15.6 weeks. The median period between the end of the second episode of treatment and commencement of the third was 11.4 weeks. Those employed had a higher probability of being retained longer in treatment than those who were unemployed in subsequent treatment episodes. Clinicians should expect that initial retention in naltrexone is likely to be relatively short, and that a substantial proportion of clients will represent for further treatment.

Using naltrexone implants in the management of the pregnant heroin user

OBJECTIVES

To describe the case history and associated obstetric and neonatal outcomes of eight women who had their heroin dependency managed over pregnancy by naltrexone implant (two x 1.8 g of naltrexone embedded in poly-DL-lactide acid) treatment.

METHOD

Case data on maternal management associated with naltrexone implant were collected at the Australian Medical Procedures Research Foundation, Perth, Australia and three Perth hospitals.

RESULTS

Despite earlier instability on oral naltrexone and repeated relapses back to dependent heroin use these women, following treatment with naltrexone implant, remained heroin free throughout their pregnancies. Neonatal and obstetric outcomes were unremarkable.

CONCLUSIONS

This case series provides preliminary evidence that the pregnant heroin user can be managed by naltrexone implant without obvious risk to the mother or developing foetus. Importantly, the current case series suggests that the pregnant woman who finds it difficult to stabilise on oral naltrexone maintenance and returns to dependent heroin use may be managed using implantable naltrexone, thereby removing from her the onus for daily naltrexone medication compliance. The authors conclude that naltrexone implant may represent an important procedure for managing the pregnant heroin dependent patient who finds it difficult to shift away from her heroin use patterns. These preliminary findings require confirmation using a much larger controlled study.

A systematic review on the efficacy of naltrexone maintenance treatment in opioid dependence

AIM

To evaluate the efficacy of naltrexone maintenance treatment in preventing relapse in opioid addicts after detoxification.

DESIGN

A systematic review according to the methodology developed by the Cochrane Collaboration based on either randomized controlled trials (RCTs) or controlled clinical trials (CCTs).

PARTICIPANTS

Seven hundred and seven heroin dependent in- and out-patients, or former heroin addicts dependent on methadone and participating in a naltrexone treatment programme; 89% were male.

INTERVENTION

Maintenance treatments on opiate dependent people after detoxification, comparing naltrexone with placebo, pharmacological or behavioural treatments.

MEASUREMENTS

The outcomes considered were successfully completed treatment, opioid use under treatment (re)-incarcerations during the study period, mean duration of treatment.

FINDINGS

The outcomes tended to be slightly although not significantly in favour of the naltrexone groups. Use of naltrexone in addition to behavioural treatment significantly decreased the probability of (re-)incarceration (OR=0.30; 95% CI 0.12, 0.76). The difficulties in producing a quantitative analysis were due mainly to the heterogeneity of the included studies.

CONCLUSIONS

From the available clinical trials performed up to this time, there is insufficient evidence to justify the use of naltrexone in maintenance treatment of opioid addicts.

Naltrexone maintenance treatment for opioid dependence

BACKGROUND

Despite widespread use of naltrexone maintenance in many countries for more than a decade, the evidence of its effects has not yet been systematically evaluated.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched MEDLINE (1973-first year of naltrexone use in humans-July 2000), EMBASE (1974-July 2000), Cochrane Controlled Trials Register (Cochrane Library issue 2001.4) and handsearched the "Bolletino per le Farmacodipendenze e l'Alcolismo" (1978 to 1997) and reference lists of relevant articles. We contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups. Date of most recent searches: December 2001.

SELECTION CRITERIA

All controlled studies of naltrexone; treatment of heroin addicts after detoxification.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated data independently and analysed outcome measures taking into consideration adherence to and success of the study intervention. Data were extracted and analysed stratifying for the three categories of study quality. Where possible, meta-analysis was performed.

MAIN RESULTS

Eleven studies met the criteria for inclusion in this review, even if not all of them were randomised. The methodological quality of the included studies varied, but was generally poor. Meta-analysis could be performed to a very low degree only, because the studies and their outcome measures were very heterogeneous. A statistically significant reduction of (re-)incarcerations was found for patients treated with naltrexone and behaviour therapy in respect to those treated with behaviour therapy only. The other outcomes considered in the meta-analysis did not yield any significant results. Final conclusions on whether naltrexone treatment may be considered effective in maintenance therapy cannot be drawn from the clinical trials available so far.

REVIEWER'S CONCLUSIONS

The available trials do not allow a final evaluation of naltrexone maintenance treatment yet. A trend in favour of treatment with naltrexone was observed for certain target groups (particularly people who are highly motivated), as has been previously described in the literature.

A compressed opiate detoxification regime with naltrexone maintenance: patient tolerance, risk assessment and abstinence rates

Opiate detoxification using methadone programmes are inefficient and expensive. Rapid and ultra-rapid detoxification using precipitated withdrawal under heavy sedation or anaesthesia provide increased efficiency and speed, but are limited by the requirement for high-dependency facilities and are perceived as high-risk procedures. Procedures using precipitated withdrawal over longer periods with lower sedation are safer, but 20% of patients fail to tolerate these. Here we evaluate a naltrexone compressed opiate detoxification (NCOD) protocol. We investigated patient acceptance, organ function and abstinence rates on 504 consecutive patients undergoing treatment at the Harrogate Detox5 centre between February 1996 and January 1999. Ninety-eight per cent of patients completed the procedure; 81% of patients reported withdrawal was "better than expected". Only 3% of patients reported any pain. Laboratory investigations demonstrated no organ dysfunction. Abstinence rates post-detox were high with 71%, 61% and 51% of patients free of opiates 3, 6 and 12 months post-detox, respectively. Compliance with the naltrexone maintenance in abstinent patients was 66%, 68% and 30% at these time points. This NCOD protocol provides an efficient method of detoxifying opiate abusers with little patient discomfort or risk to health. Abstinence rates are better than those in comparable studies using other programmes.

Compliance to naltrexone treatment after ultra-rapid opiate detoxification: an open label naturalistic study

Studies have found that naltrexone, a long-acting opiate antagonist, owing to poor patient compliance, is of limited value in preventing relapse. The current study investigates compliance with a 9-month course of naltrexone (25-50 mg daily) given with counseling after ultra-rapid opiate detoxification which uses clonidine and naltrexone under general anesthesia. Eighty-three of 113 randomly selected patients (out of 640), who were detoxified more than 1 year prior (average 1.5 years), responded to phone interviews. Phone questionnaire asked about patients' compliance with naltrexone, counseling and drug use since detoxification. Similar interviews were also conducted with patients' significant other. Non-relapse patients (n = 47, 57%) took naltrexone an average of 2 months longer than did relapse patients (n = 36, 43%). About half of the non-relapse patients completed at least 5 months of naltrexone, 30% completed at least 7 months and about 20% completed 9 months. Fifty-five percent of the relapse patients stopped using naltrexone by the end of the 3rd month, and by the end of 7th month 10% continued to take it. After the first 2 months the decline in naltrexone compliance was about the same for relapse and non-relapse patients. These results are more encouraging about the use of naltrexone for relapse prevention than previous studies. This method of using naltrexone should be further tested in prospective random assignment controlled studies.

Nonpharmacologic approaches to substance abuse treatment

Familiarity with nonpharmacologic approaches to substance abuse treatment is critical for medical practitioners to act effectively to prevent the progression of substance use to medically harmful use, abuse, or dependence; to identify patients with substance use disorders and motivation behavioral changes; and to maximize the likelihood of successful treatment. At their most basic level, these nonpharmacologic approaches involve components of practice that are requisite to the successful management of any medical disorder: fostering an empathic, supportive relationship; routinely evaluating the system or problem area; providing accurate medical information about diagnosis, natural history, and treatment; and following up on identified problems to improve compliance, evaluate the impact of treatment, and modify treatment as indicated. Because of the nature of substance use disorders, their impact on multiple areas of functioning, and the conditioned craving that occurs following repeated substance use, nonpharmacologic treatments can improve outcome, even when effective pharmacologic treatments are also employed. Treatment of nicotine dependence provides a useful example. Physician advice to stop smoking substantially increases the likelihood of smoking cessation and long-term abstinence. Combined with physician advice, nicotine replacement therapies, using nicotine gum or transdermal preparations, approximately double the rate of long-term abstinence, compared with physician advice alone. Providing behavioral treatment in addition to physician advice and nicotine replacement treatment leads to the highest rates of sustained abstinence, significantly higher than advice alone or rates associated with nicotine replacement alone. Nonpharmacologic treatments complement pharmacologic approaches often by addressing different target symptom and problem areas. In the case of nicotine dependence, nicotine replacement ameliorates withdrawal symptoms and craving associated with withdrawal. Behavioral treatment improves outcome by focusing on cue-evoked craving and developing effective long-term strategies to avoid or cope with craving and other cues. As discussed in this article, brief motivation approaches are particularly well suited for general medical practice settings. These approaches have been evaluated most extensively and shown to be most effective in preventing the progression of heavy drinking to problem drinking and alcohol dependence. Following a thorough evaluation of a patient's drinking habits, providing advice about sensible and safe drinking to patients identified as heavy drinkers leads to meaningful reductions in drinking. For patients who have developed problems of abuse or dependence, motivation approaches can be used to foster an interest and commitment to stop use and accept a referral to treatment. This article also provides an overview of the major psychosocial approaches used in more intensive specialty treatment of patients with substance use disorders. Familiarity with these approaches is essential for clinicians in general medical settings to facilitate referral of patients and monitor and improve the efficacy of treatments provided to patients. Medical practitioners must be able to educate patients about the need for more intensive specialty treatment and about what treatment entails. Medical practitioners must also be able to engage in informed discussions with substance abuse treatment specialists about the specific treatment recommendations made for a patient and the rationale for them. Medical practitioners who are informed about the treatment plans, rationale for treatment, and patient progress can play critical roles in encouraging patients to persist with the often difficult process of treatment.

Naltrexone plus group therapy for the treatment of opiate-abusing health-care professionals

PURPOSE

The success rate of a treatment program tailored to opioid-abusing health-care professionals that included oral naltrexone and group therapy was studied.

METHODS

20 opioid-abusing health professionals were treated over a 5-year-period. Clients received an initial assessment, supervised administration of naltrexone, and weekly attendance at a psychotherapy group for health professionals. Naltrexone was administered for the first several months, then patients continued the program without naltrexone.

RESULTS

18 patients were referred to the program after being caught diverting medication. Two patients came spontaneously. Of the 18 referred patients, 12 had no relapses, and 5 had only one relapse, followed by long-term sobriety. Mean overall duration of naltrexone administration was 8 months, and the mean duration in the program was 1.9 years. 94% of referred clients had long term abstinence, and 66% were working in their profession during the program.

CONCLUSIONS

Naltrexone in the setting of a structured program is helpful in the treatment and professional reinstatement of opioid abusing health professionals.

Naltrexone. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in the management of opioid dependence

Naltrexone is a long acting competitive antagonist at opioid receptors which blocks the subjective and objective responses produced by intravenous opioid challenge. It is suitable for oral administration, and has been studied as an adjunct for use in opioid addiction management programmes. In non-comparative clinical trials involving detoxified patients, oral naltrexone reduced heroin craving and between 23 and 62% of patients remained in treatment after 3 to 4 weeks. However, in two studies 32 to 58% of patients who continued in treatment were opioid-free between 6 and 12 months after stopping naltrexone. As might be expected studies involving highly motivated patients have shown this type of patient group to achieve greater treatment success rates during naltrexone therapy, and remain opioid-free longer than other groups of apparently less motivated patients. In addition, when naltrexone is combined with family support, psychotherapy and counselling, patients are more likely to remain opioid-free. Naltrexone produces a low incidence of side effects, with gastrointestinal effects being the most commonly reported symptoms. Thus, despite the overall high attrition rates from trials, in selected patient groups and in combination with appropriate support mechanisms and psychotherapy, naltrexone represents a useful adjunct for the maintenance of abstinence in the detoxified opioid addict.

Relationship of marital structure and interactions to opiate abuse relapse

Several aspects of marital functioning were associated with subsequent relapse to opiate abuse in 17 married addicts. The addicts and spouses were evaluated in a task-oriented interview and rated using the Beavers Timberlawn Family Assessment instrument. The global health-pathology ratings on this instrument indicated that most couples had rigid patterns of interacting, rather than a chaotic lack of structure or a flexible, negotiated partnership. Within this range of rigid functioning, higher ratings were associated with longer times drug-free (up to 18 months with a mean of 7 months). On the seven subscales of the Beavers', five were significantly correlated with the time drug-free: effective and clear leadership, closeness between the spouses, a nonhostile mood, empathy, and efficient negotiation and problem solving. The subscales associated with drug abstinence were quite different for a group of seven single ex-addicts participating in the same outpatient program, but living with their parents. For these single ex-addicts three subscales were correlated with the time drug-free: parental reaction to separation strivings, the open expression of thoughts and feelings, and empathy. This difference in the subscales associated with abstinence for married versus single addicts suggested some specificity in the characteristics of family structure and interaction that may be related to drug abstinence.

Psychosocial factors in outcome in two opiate addiction treatments

Thirty naltrexone and 30 methadone patients in outpatient opiate addiction treatment were compared on pretreatment somatization, stress, and family support. Also, the relationship between these pretreatment variables and outcome in terms of drug abuse and retention was examined. In the methadone group, drug abuse was correlated significantly with somatization, stress, and family support. In the naltrexone group, retention was correlated significantly with somatization and stress. Treatment and research considerations were discussed.

Psychotherapy/counseling for opiate addicts: strategies for use in different treatment settings

The authors review evidence from outcome studies of psychotherapy for opiate addicts and make recommendations regarding the use of psychotherapy on the basis of the findings. The place of psychotherapy is evaluated for three types of treatment settings: outpatient drug-free treatment, narcotic antagonist treatment, and methadone maintenance. The heterogeneity of opiate addicts is emphasized, as is the need for multidimensional assessment of clients in order to maximize the effectiveness of psychotherapies offered. In each of the treatment settings evaluated, psychotherapy appears to be most promising for a subgroup of those seen. For outpatient drug-free treatment, psychotherapy appears to be most useful for the new client with no treatment history, the successful client graduating from a more intensive program, the client who has temporarily relapsed, and the client leaving jail or a hospital. In a narcotic antagonist program, psychotherapy appears to be most useful for clients entering the program from illicit heroin use and not for those switching from methadone maintenance to a narcotic antagonist program. Moreover, in the maintenance phase of the program, preliminary evidence suggests the value of family therapy for aiding treatment retention. Regarding psychotherapy in the context of a methadone maintenance program, it appears to be best reserved for those addicts who present to treatment with relatively severe levels of psychiatric symptoms.

Strategies to improve compliance with narcotic antagonists

The pharmacologic promise of naltrexone has not been matched by therapeutic usefulness. Plagued by difficulties in the induction period and very high dropout, the drug remains limited to a very small segment of the opiate-addited population. Some programs have managed, however, to substantially improve on these problems and such strategies will be discussed. The paper will look at the different problems raised during the high dropout periods of induction, the first month of stabilization, and the later stages of maintenance. It will then focus on methods to deal with these problems. Strategies examined will include among others individual and group counseling, family and couples' therapy, and contingency contracting. Strengths and weaknesses of each of these both from our own 7 years of experience and in the literature will be examined.

Complementary marital roles of male heroin addicts: evolution and intervention tactics

Using Haley's concept of complementary and symmetrical relationships, we intensively studied the role relationships of 28 male heroin addicts and their spouses. These couples had no symmetrical role relationships, but had an alternating sequence of two complementary role relationships. These complementary roles sequentially alternated from a compliant child with a nurturing mother, when the wife would deny her husband's drug abuse; to a rebellious son with a policing mother, when a financial or legal crisis would force her to confront his addiction. After this crisis, the couple entered treatment in the unstable complementary roles of contrite child and policing mother. During treatment, the wife was educated and supported to confront early signs of drug abuse, thus avoiding its denial, and the couple was encouraged to develop symmetrical roles by beginning to share minor responsibilities.