A rapid detoxification regimen that is conducted under general anesthesia was popular in a number of centers as a means of treating opiate addiction has now been largely abandoned for reasons of safety but it could be resurrected if other more conventional approaches continue to be futile. The technique consisted of administering increasing doses of opioid receptor antagonists (naloxone or naltrexone) over several hours while the autonomic and other features of the withdrawal syndrome were suppressed by the infusion of propofol or a similar anesthetic, supplemented by intravenous fluids. Medications such as clonidine and sedatives were also given in the immediate postanesthetic period. There are substantial risks involved in this procedure and several deaths have occurred for which reason it has been all but abandoned. Furthermore, a number of patients continue to manifest signs of withdrawal after the procedure and require continued hospitalization.
Treatment of opiate habituation This is in some ways far more demanding than the treatment of opioid withdrawal and can be best accomplished in special facilities and programs that are devoted wholly to the problem. These are available in most communities. The most effective ones have been the ambulatory methadone maintenance clinics, where more than 100,000 former heroin addicts are participating in rehabilitation programs approved by the FDA. Methadone, in a dosage of 60 to 100 mg daily (sufficient to suppress the craving for heroin), is given under supervision day by day (less often with long-acting methadone) for months or years. Various forms of psychotherapy and social service counseling often administered by former heroin addicts are integral parts of the program.
The results of methadone treatment are difficult to assess and vary considerably from one program to another. Even the most successful programs suffer an attrition rate of approximately 25 percent when they are evaluated after several years. Of the patients who remain, the majority achieves a degree of social rehabilitation, that is, they are gainfully employed and no longer engage in criminal behavior.
The usual practice of methadone programs is to accept only addicts older than age 16 years with a history of heroin addiction for at least 1 year. This leaves many adolescent addicts untreated. The number of addicts who can fully withdraw from methadone and maintain a drug-free existence is very small. This means that the large majority of addicts now enrolled in methadone programs are committed to an indefinite period of methadone maintenance and the effects of such a regimen are uncertain.
An alternative method of ambulatory treatment of the opiate addict involves the use of narcotic antagonists, of which naloxone and naltrexone are the best known. The physical effects of abusing narcotics are thereby partially blocked, and there may be some degree of aversive conditioning if withdrawal symptoms are produced. Naltrexone is favored because it has a longer effect than naloxone, is almost free of agonist effects, and can be administered orally. Similar results have also been achieved with cyclazocine in a small number of highly motivated patients; this drug is administered orally in increasing amounts until a dosage of 2 mg/70 kg body weight is attained. The drug is taken bid (for 2 to 6 weeks) and is then withdrawn slowly.