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For patients with a prolonged history (>1 year) of opioid dependence, consider providing agonist maintenance treatment (e.g., methadone or buprenorphine).

  • Agonist maintenance treatment reduces the morbidity, mortality, and other deleterious effects associated with opioid dependence, even if abstinence is never achieved.

  • Treatment aims to facilitate engagement in a comprehensive program of rehabilitation that can improve overall functioning through addressing substance use, psychosocial issues, and psychiatric and somatic needs.

  • Implementation is described in Table 8.

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Implementation of Methadone, Buprenorphine, or Naltrexone

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Table Reference Number
Implementation of Methadone, Buprenorphine, or Naltrexone

As an alternative strategy, consider maintenance therapy using naltrexone, an opioid antagonist that blocks effects of usual street doses of opioids.

Clonidine pretreatment can minimize naltrexone-precipitated withdrawal symptoms in opioid-dependent patients who are in transition to narcotic antagonist treatment, but patients must be monitored for the initial 8 hours (because of the potential severity of naltrexone-induced withdrawal) as well as receive careful monitoring of blood pressure throughout withdrawal.

Avoid use of ultrarapid opioid detoxification.

Induction of opioid withdrawal by administration of naltrexone while patients are under general anesthesia has an adverse risk/benefit ratio and a lack of proven efficacy.

Consider combining psychosocial treatments with opioid agonist or antagonist therapies to improve treatment adherence and prevent relapse.

The following treatments may be helpful:

  • Cognitive-behavioral therapies

  • Behavioral therapies including contingency management

  • Psychodynamic psychotherapies

  • Drug counseling

  • Group and family therapies

  • Self-help groups

Table Reference Number
Implementation of Methadone, Buprenorphine, or Naltrexone

References

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