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Chapter 20. Opioid Maintenance Treatment

Richard S. Schottenfeld, M.D.
DOI: 10.1176/appi.books.9781585623440.351947

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Excerpt

Opioid dependence (i.e., dependence on opiate or opiate-like drugs) is a chronic and severe psychiatric disorder associated with substantial risk of mortality, medical and other psychiatric morbidity, and adverse social, vocational, familial, and legal consequences. As with other chronic and severe medical or psychiatric disorders, the goals of treatment are to prevent or reduce the adverse medical, psychiatric, and other consequences of the disorder and to improve the patient's functioning, quality of life, and overall well-being.

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Table Reference Number
TABLE 20–1. Medication interactions with methadone
Table Reference Number

More than 40 years of clinical research and clinical experience with methadone maintenance treatment have established the efficacy and effectiveness of this treatment for reducing illicit opioid use and for reducing the mortality and morbidity associated with opioid dependence. Based on a thorough and critical review of the literature, a recent Institute of Medicine committee concluded that the scientific evidence supports the effectiveness of methadone maintenance treatment for reducing heroin and other illicit opioid use, retaining patients in treatment, and reducing criminal activity, mortality, drug-related HIV risk behaviors, and the risk of HIV transmission associated with heroin dependence (Institute of Medicine Committee on the Prevention of HIV Infection among Injecting Drug Users in High Risk Countries 2006Institute of Medicine Committee on the Prevention of HIV Infection among Injecting Drug Users in High Risk Countries 2006).

Critical factors determining the effectiveness of methadone maintenance treatment include treatment duration, methadone dose, and provision of counseling and other services. The Institute of Medicine committee also concluded that longer-term maintenance treatment is more effective than shorter-term treatment and that the effectiveness of methadone maintenance is improved when sufficient daily methadone dosages are provided and when patients receiving methadone maintenance treatment are provided drug counseling and ancillary vocational, medical, or other needed services.

Clinical challenges during methadone maintenance treatment include co-occurring other substance use and psychiatric or medical disorders. These co-occurring disorders respond to specific treatments, and treatment for co-occurring disorders is facilitated by integrating or coordinating it with methadone maintenance treatment.

From a public health standpoint, the most important challenge is to improve the availability and accessibility of methadone or other opioid agonist maintenance treatment so that all heroin- or other opioid–dependent patients can receive this treatment for as long as needed.

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The transition from heroin use to dependence carries a dire prognosis. Hser et al. (2001) studied 581 heroin-addicted men for more than 30 years after admission to a compulsory drug abuse treatment program in California. Based on this study, which of the following statements is false?
2.
Which of the following statements concerning the clinical pharmacology of methadone and l--acetyl-methadone (LAAM) is true?
3.
There are a number of potential medication interactions with methadone. Which of the following medications may reduce plasma methadone levels?
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