Serum propoxyphene concentrations in a cohort of opiate addicts on long-term propoxyphene maintenance therapy. Evidence for drug tolerance in humans

Propoxyphene, norpropoxyphene, and cyclic dinorpropoxyphene concentrations in the sera of eight opiate addicts were measured by gas chromatography. The addicts were enrolled in a propoxyphene maintenance program and had received 800-1600 mg of propoxyphene napsylate daily for 13-50 months. Serum propoxyphene and norpropoxyphene ranged from 127 to 1070 ng/mL and 814 to 2638 ng/mL, respectively, and their ratio ranged from 0.1 to 0.4. A roughly linear dose-to-serum-concentration relationship was found for serum propoxyphene and norpropoxyphene in the cohort. Cyclic dinorpropoxyphene was detected in three of the subjects' sera. Because tolerance to propoxyphene occurs, knowledge of prior drug exposure is necessary to determine whether an elevated propoxyphene or norpropoxyphene concentration is toxic to patients or decedents with apparent propoxyphene overdose. Serum norpropoxyphene concentration exceeds that of propoxyphene following chronic propoxyphene use. Measurable cyclic dinorpropoxyphene implies chronic propoxyphene use but its absence does not exclude chronic use.

Inadequate plasma concentrations in some high-dose methadone maintenance patients

The author studied 18 heroin addicts who had been maintained on 80 mg/day of methadone and who abused drugs or alcohol. His findings suggest that in some cases of aberrant methadone metabolism, the dose can be raised to achieve plasma concentrations adequate to eliminate drug and alcohol abuse.

Naltrexone treatment for postconcussional syndrome

Two patients with postconcussional syndrome whose most severe symptoms were blackouts, headaches, and amnesia episodes appeared to respond to naltrexone. Because life-saving emergency trauma services are widely available, it is likely that the incidence of postconcussional syndrome will increase.

Double-blind comparison of amantadine and bromocriptine for ambulatory withdrawal from cocaine dependence

Amantadine hydrochloride and bromocriptine mesylate were compared on a double-blind basis for withdrawal from cocaine dependence. Both amantadine and bromocriptine appear effective in alleviating the symptoms of cocaine withdrawal. In doses higher than previously reported, however, bromocriptine caused enough side effects to produce treatment dropouts; neither drug produced euphoria. Amantadine appears to primarily exert its therapeutic influence by releasing dopamine and norepinephrine from neuronal storage sites that are depleted by chronic cocaine dependence, and bromocriptine acts as a dopamine agonist and stimulates dopamine receptors.

Clinical experiences with 959 opioid-dependent patients treated with levo-alpha-acetylmethadol (LAAM)

Levo-alpha-acetylmethadol (LAAM) is an orphan drug that will soon be generally available to treatment facilities. We have recently treated 959 opioid addicts with LAAM for periods up to 36 consecutive months. Three times per week dosing of LAAM proved to be a safe and effective treatment agent for the majority of subjects. During LAAM induction there is a delay in opioid activity as LAAM forms its long-acting metabolites, therefore, symptomatic withdrawal medication must usually be administered during the first 96 hours of treatment to adequately suppress opioid withdrawal symptoms and prevent self-administration of drugs by the patient. No long-term hepatic toxicity or tumor formation could be demonstrated by liver function studies and liver-spleen imaging in a subgroup of patients. Some opioid addicts report that they prefer LAAM over methadone, but the reverse was reported by about 40% of our patients which suggests that both drugs are needed for adequate maintenance treatment of the opioid-addicted population.

Cocaine plasma concentrations in persons admitted to outpatient treatment: relationship to treatment outcome

Nine (9) of 23 (39.1%) consecutive persons who sought outpatient treatment for chronic cocaine dependence had detectable plasma cocaine concentrations on admission which ranged from 10.0 to 639 ng/ml (mean 146.9 +/- 202.2). Subjects with cocaine in their plasma demonstrated at least partial tolerance to acute cocaine effects in that there was no consistent presence of hypertension, tachycardia, accelerated speaking rate, hyperreflexia, or dilated pupil. Subjects who were admitted with cocaine in their plasma retained in treatment only 4.6 +/- 4.0, compared to 13.0 +/- 13.4 days among those admitted with cocaine in their plasma (P less than .05). In addition, 11 of 14 (78.6%) subjects without cocaine in plasma compared to 2 of 9 (22.2%) with cocaine in plasma produced a urine void of cocaine metabolite during treatment. (P less than .01)

Subjective perceptions to the intravenous "rush" of heroin and cocaine in opioid addicts

Subjective responses to intravenous heroin and cocaine administration were investigated by questionnaire in a population of 40 male and 29 female confirmed heroin addicts. Responses of males and females were very similar for the heroin rush, ranking pleasure, relaxation, satisfaction, warmth, and thirst highest among 20 feelings surveyed and ranking feelings like sexual orgasm low, only fifteenth out of 20. Responses of males and females for the cocaine rush were similar in that both ranked excitement, pleasure, thirst, strength, and anxiety very high, in the top six responses, and both rated feelings like sexual orgasm relatively low, rank 9 for males and 15 for females. However, male and female responses for cocaine differed in that males ranked power very high, rank 2; and females ranked power relatively low, rank 10; but ranked satisfaction, rank 5; warmth, rank 5; and relaxation, rank 12; much higher than males who ranked them 15, 16, and 17, respectively. Despite the fact that sexual feelings were infrequently identified with rushes, the results best supported an interpretation that the population was largely inorgasmic without drugs, but found attractive orgasmic pleasure in heroin and cocaine. Males and females perceived the cocaine rush differently, but the reason of these differences is uncertain.

Benefits of recurrent, outpatient heroin detoxification

Recurrent heroin detoxification, or the "revolving-door" process, is the treatment of choice for many addicts. Forty-five heroin addicts were detoxified 145 times (mean = 3.2 per patient) on an outpatient basis over a 3-year period and showed significant improvement in arrest and hospitalization rates but not employment or intact marriages. Another group of 74 patients who had detoxified two or more times were compared to a similar group of 61 methadone maintenance (mean maintenance time = 17.9 weeks) patients, and no significant difference was found in a variety of health, employment, and social indicators. These findings indicate that recurrent, outpatient heroin detoxification has some therapeutic benefits and provides an explanation for patient popularity.

Effect of cocaine dependence on plasma phenylalanine and tyrosine levels and on urinary MHPG excretion

Eight cocaine-dependent subjects had significantly lower urinary 3-methoxy-4-hydroxyphenylglycol excretion than did eight normal control subjects. Cocaine-dependent subjects also had lower plasma tyrosine levels but not to a statistically significant degree.

Alterations in catecholamine metabolism partially corrected during amphetamine-dependence

A woman appeared to clinically benefit from high doses of amphetamine taken for a period of 27 years. During amphetamine administration, elevated urinary 3-methoxy-4-hydroxy-phenylglycol (MHPCG) excretion values returned to normal accompanied by reductions in plasma phenylalanine.

Clinical experience with naltrexone in suburban opioid addicts

In a study of 160 patients (including 114 active heroin addicts and 42 former heroin addicts maintained on methadone, propoxyphene napsylate, or LAAM), subjects were retained on treatment with naltrexone for a mean of 50.7 days (range, 1-635). Clonidine or guanabenz acetate was used to detoxify subjects who received naltrexone within 10 days of their last dose of opioid. Because of the number of subjects dropping out of treatment after only a few days, it is recommended that there be an opioid-free period of 5 or more days for heroin-dependent subjects and 10 or more days for those on medical maintenance. A naloxone challenge should be administered at a dosage of 0.8 mg. Use of naltrexone combined with psychotherapy appears to promote long periods of opioid abstinence but does not prevent relapse after treatment. Trained clinicians utilizing an appropriate induction protocol can effectively treat volunteer opioid addicts with naltrexone.

Clonidine hydrochloride detoxification from methadone treatment--the value of naltrexone aftercare

Treatment outcomes were compared for 2 groups of subjects detoxified from methadone using clonidine. One group of 12 subjects was encouraged to continue in treatment with naltrexone, while the other 12 subjects did not have naltrexone treatment available. Results suggested that those subjects who had naltrexone available were more successful at completing the 10 day detoxification treatment and that the relapse rate at 30 days post-treatment was significantly reduced by naltrexone treatment.

Clinical evaluation of mecamylamine for withdrawal from nicotine dependence

Mecamylamine (MCL) has been shown to extinguish nicotine dependence in rats and monkeys. MCL was administered to fourteen nicotine-dependent persons to determine if it may be effective in withdrawing nicotine-dependent humans at doses which have acceptable toxicity. Subjects smoked 20 to 60 cigarettes per day for a mean of 2.4 years, and none had been nicotine abstinent for as much as one day for at least one year. MCL was started in a dose of 5 to 10 mg per day and progressively raised until the subject experienced nicotine blockage and/or toxic effects. During MCL administration, 7 of 14 (50%) totally ceased smoking within the first 11 days of treatment, and an additional 4 (28.6%) subjects reduced cigarette consumption to less than five per day by the end of three weeks. Thirteen of 14 (92.9%) subjects stated that MCL blocks nicotine, reduces nicotine craving, and "works." At least some minor side-effects of MCL were observed in every subject. The most intolerable side-effects were constipation, urinary retention, abdominal cramps, and weakness, and these were responsible for drop-out of 5 (35.7%) subjects. Although there is a high prevalence of side-effects, MCL is probably a viable withdrawal treatment for some cases of recalcitrant nicotine dependence.

Methadone plasma levels and persistent drug abuse in high dose maintenance patients

Methadone maintenance patients who maintained on a high daily dose were divided into good performers and poor performers based on whether they demonstrated persistent use of heroin, non-prescription diazepam, and/or excessive alcohol consumption. Mean methadone plasma levels 24 hours after an oral dose of 80 mg were found to be 410.4 ng/ml in good performers compared to 101.8 ng/ml in poor performers (P less than .05). Seven of nine (77.8%) poor compared to two of 15 (13.3%) good performers had 24-hour methadone plasma levels under 50 ng/ml (P less than .01). High dose methadone patients who show evidence of persistent drug or alcohol abuse should have their 24-hour methadone plasma level determined to help assess whether the patient should receive more methadone or find an alternative treatment.

Five-year follow-up of opiate addicts with naltrexone and behavior therapy

A group of 58 heroin addicts were treated with naltrexone and behavior therapy and followed for 5 years. At one-year post-treatment, almost half of the naltrexone-treated subjects were opiate free. Follow-up results at 5 years post-treatment indicate that over 90% of those patients treated with naltrexone became re-addicted for various periods of time. However, naltrexone-treated subjects did feel their treatment with naltrexone had provided them with the ability to remain opiate free for blocks of time. The results suggest that naltrexone is not a "cure" for opiate dependence, but is a medication which can be useful in protecting patients from re-addiction and is a modality patients should be encouraged to return to if they feel vulnerable to re-addiction.

Guanabenz acetate: a new, long-acting alpha-two adrenergic agonist for opioid withdrawal

Guanabenz Acetate (GA) is a new long-lasting alpha-two agonist. We found that it effectively suppressed opioid withdrawal in the majority of 47 opioid-dependent subjects. GA was usually given in twice per day dosages and did not appear to have as many side effects as clonidine. It may have greater acceptance among heroin addicts than clonidine.

(-)-alpha-Acetylmethadol for treatment of chronic pain patients who abuse opioids

(-)-alpha-Acetylmethadol (LAAM) is an opioid with a duration of action up to 72 h. It appeared to relieve pain and eliminate abuse of opioids in three of four patients who had chronic pain secondary to permanent, anatomical alterations. LAAM may be very helpful in the treatment of many chronic pain patients.

Efficacy of psychotherapeutic counselling during 21-day ambulatory heroin detoxification

Structured, psychotherapeutic counselling during 21-day heroin detoxification was evaluated by randomly assigning a group of 25 heroin addicts to a detoxification treatment regimen with mandatory counselling by a therapist and 25 to a control group who received only standard detoxification without counselling. There was no significant difference between groups in the number who successfully detoxified as measured by conversion of morphine positive urine to morphine negative urine. The counselling intervention group did, however, improve the attendance of subjects while in detoxification treatment, and significantly more patients entered long-term treatment following detoxification. Maximal use of a counselor during 21-day heroin detoxification may best be realized by directing therapy toward engaging patients in long-term care.

Acanthosis nigricans in adolescents. Two case reports and guidelines for management

Acanthosis nigricans (AN) is a dermatologic condition of the flexor surfaces of the body consisting of papular hypertrophy, hyperpigmentation, and rugae. AN is commonly associated with malignancy when in adults but is primarily associated with endocrinologic disorders and obesity when found in adolescents. A special search for occult malignancy is not warranted in adolescents with AN unless no associated benign condition is found. Careful follow-up is recommended, however, since AN may be the first indication of a serious systemic disease.

Outpatient treatment of prescription opioid dependence: comparison of two methods

Outpatient treatment of 42 patients who presented with dependence upon prescription opioids was attempted by two different methods. The first group of 21 patients was treated by 21-day detoxification followed by psychotherapeutic counseling (D/C), and the next 21 patients were offered 21-day detoxification to be followed by opioid maintenance if detoxification was unsuccessful (D/M). Only 5 of 21 (23.8%) patients in the D/C group compared to 20 of 21 (95.2%) in the D/M group completed three weeks of treatment (P less than .001). On admission, no patient perceived that chronic pain due to a medical condition would be an impediment to withdrawal from opioids, but pain which was masked by opioid dependency and which emerged during detoxification proved to be an insurmountable barrier to total withdrawal in the majority of patients. Treatment of outpatients who presented with dependence upon prescription opioids was best provided in the study by opioid maintenance and adjunctive pain therapy.

Efficacy of psychotherapeutic counselling during 21-day ambulatory heroin detoxification

Structured, psychotherapeutic counselling during 21-day heroin detoxification was evaluated by randomly assigning a group of 25 heroin addicts to a detoxification treatment regimen with mandatory counselling by a therapist and 25 to a control group who received only standard detoxification without counselling. There was no significant difference between groups in the number who successfully detoxified as measured by conversion of morphine positive urine to morphine negative urine. The counselling intervention group did, however, improve the attendance of subjects while in detoxification treatment, and significantly more patients entered long-term treatment following detoxification. Maximal use of a counselor during 21-day heroin detoxification may best be realized by directing therapy toward engaging patients in long-term care.

Cocaine and amphetamine dependence treated with desipramine

Desipramine was administered to 8 amphetamine- and 14 cocaine-dependent persons to assist withdrawal. Nineteen of 22 (86.4%) reported discontinuation of drug use within two to seven days, of which 15 (68.2%) gave urine samples negative for amphetamines or cocaine. Recent primate studies show that chronic methamphetamine administration markedly depletes brain norepinephrine, which suggests that desipramine is probably effective in treating amphetamine and cocaine dependency because it selectively blocks norepinephrine uptake.

Outpatient treatment of prescription opioid dependence: comparison of two methods

Twenty-one patients dependent on prescription opioids were treated by 21-day detoxification followed by psychotherapeutic counseling (D/C), and 21 patients were detoxified 21 days and provided opioid maintenance if detoxification was unsuccessful (D/M). Only five of 21 (23.8%) patients in the D/C group compared with 20 of 21 (95.2%) in the D/M group completed three weeks of treatment. No patient initially perceived that chronic pain due to a medical condition would be an impediment to withdrawal from opioids, but pain that was masked by opioid dependency and that emerged during detoxification proved to be an insurmountable barrier to total withdrawal in the majority of patients. Treatment of outpatients with dependence on prescription opioids is best provided by opioid maintenance therapy and adjunctive pain therapy.

Propoxyphene napsylate maintenance treatment of narcotic dependence: use of a non-methadone model

One hundred seventy-eight (178) heroin addicts entered propoxyphene napsylate (PN) maintenance. Patients attended a general medical clinic two times each week and took home a three- to four-day supply of PN which was usually taken in doses of 300 to 400 mg three to four times per day. Over a 21-month period, the subjects entered and re-entered PN treatment 166 times (1.5 times per patient) and remained a mean of 10.6 weeks per treatment. A comparison with a group of methadone maintenance patients indicated similar performance in employment and heroin use. The ability to take PN, attend a clinic less often than daily, and discontinue and re-enter treatment on a discretionary basis is preferred treatment approach for some narcotic addicts.

Peripheral blood findings associated with asymptomatic lead exposure

This study was done to determine whether erythroid alterations can be found on a peripheral blood smear from an asymptomatic person exposure to excess atmospheric lead. Thirty healthy, asymptomatic adults who lived within five miles of a major Los Angeles, California freeway for five consecutive years were studied. Erythroid cytologic alterations-including-anisocytosis, poikilocytosis, polychromasia and basophilic stippling were statistically associated with increased free erythrocyte protoporphyrin levels. These findings indicate that erythroid alterations may be found on a peripheral blood smear prior to the development of clinical symptoms of lead intoxication.

Characteristics of 68 chronic phencyclidine abusers who sought treatment

An analysis of 68 phencyclidine (PCP) users who sought treatment reveals that chronic compulsive, daily use occurs and that intravenous use is relatively common. Twenty-five (37%) subjects considered themselves to be addicted to PCP and 19 (29%) desired medication to assist withdrawal. Unwanted behaviors under the influence of PCP were common and primarily related to memory loss, or acts which resulted from loss of impulse control.

Propoxyphene napsylate maintenance treatment for narcotic dependence: a non-methadone model

One hundred and seventy eight heroin addicts entered propoxyphene napsylate (PN) maintenance. Patients attended a general medical clinic twice each week and took home a three- to four-day supply of PN, to be taken in doses of 300 to 400 mg three or four times per day. Over a 21-month period, subjects entered and re-entered PN treatment 266 times (1.5 times per patient) and remained in treatment a mean of 10.6 weeks. When compared with a group of methadone maintenance patients, similar characteristics in employment and heroin use were found. The ability to take PN, attend a clinic less often than daily and discontinue and re-enter treatment on a discretionary basis is a preferred treatment approach for some narcotic addicts.

The California registration system for habitues to schedule II drugs

In order to help control abuse and prevent over-prescribing, California has developed triplicate prescriptions for Schedule II narcotics as well as a system for physicians to publicly register patients who are habitues to Schedule II Controlled Substances. A preliminary evaluation indicates that there is under-reporting and confusion among physicians about the system, but it has probably helped control Schedule II narcotic abuse in California while not depriving patients of needed treatment. Physicians appear to prescribe Schedule II narcotics for serious medical conditions but may underprescribe narcotics for some chronic pain patients and subject others to potential complications of high, chronic doses or oral narcotics which are combined with salicylate, acetaminophen, or phenacetin. Despite some defects, California's system of triplicate prescriptions and public registration of habitues appears a viable alternative to the removal of abusable, Schedule II drugs from the commercial market.

Prescribing narcotics to habitual and addicted narcotic users. Medical and legal guidelines in California and some other Western states

Confusion exists among physicians over the legal requirements and appropriate prescribing of narcotics to addicted or habitual users of narcotics. The result has often been either (1) the deprivation of appropriate treatment for patients who desire detoxification or adequate pain relief, or (2) illegal prescribing by physicians. Because most narcotics are potent and dangerous substances, certain legal restrictions are necessary to protect the general public. State-approved programs have been established to prescribe methadone and propoxyphene napsylate for addiction treatment. Current laws and regulations in California permit every practicing physician to provide effective and safe treatment for addiction and pain relief.

Influence of a cash fee on outpatient heroin detoxification

Twenty-eight employed heroin addicts who were admitted to 10-day, outpatient detoxification and paid a modest fee were compared to 28 poverty-level, unemployed patients who received free detoxification. Patients were matched for admission date within +/- 30 days, sex, age within +/- 5 years, total length of heroin use within +/- 3 years, and parole/probation status. At the end of detoxification treatment, 9 of 28 (32.1%) patients who paid a fee, and 11 of 28 (39.3%) patients who were given free treatment had urines which were devoid of heroin derivative (PNS). Three of less patients in each group chose to remain in longer-term treatment (PNS). These results suggest that a patient fee did not favorably influence outcome of outpatient heroin detoxification.

Screening for drug and alcohol abuse in a general medical population

One hundred fifty consecutive, first-visit, general medical patients were simply and inexpensively screened by questionnaire, personal inquiry, and physical examination for drug and alcohol abuse. Seventeen (11.3%) currently used psychoactive drugs, excluding alcohol, and ten (6.7%) used drugs or alcohol on a daily basis to the point that the patient considered it an abuse problem. The majority of the drug and alcohol users recognized their problem on a short questionnaire that was part of a medical intake form. Almost all of the recognized abusers of drugs or alcohol subsequently entered treatment of their problem.