Management of relapse in naltrexone maintenance for heroin dependence.
Opioid dependence is a growing public health problem. Maintenance on the antagonist naltrexone for clinic- or office-based treatment of opioid dependence is plagued by high rates of relapse. This paper identifies critical determinants of lapses to opioid use during naltrexone maintenance. Time retained in treatment was examined as a function of whether lapses to opioid use occurred while adherent to naltrexone (blocked use), or after having missed naltrexone doses (unblocked).


METHODS
Participants (N=83) met DSM-IV criteria for opioid dependence and identified a significant other willing to participate in their treatment. Following inpatient detoxification, participants were enrolled in a 26-week outpatient course of therapy and naltrexone maintenance.


RESULTS
Patients with unblocked use had a very high rate of dropout (10% retained at 6 months), dropout usually occurring within 2 weeks after unblocked use. Patients with only blocked use had less dropout (33% retained at 6 months). However, episodes of blocked use were often followed by unblocked use and dropout.


CONCLUSIONS
During naltrexone maintenance for opioid dependence unblocked opioid use calls for immediate intervention, such as detoxification or switching to the partial agonist buprenorphine. Episodes of blocked use warrant increased clinical attention, such as direct observation of naltrexone ingestion, increased dose, or increased intensity of treatment contact. Maintenance on oral naltrexone is a fragile treatment because it is so easily undermined by episodes of opioid use while non-compliant. New long-acting injectable or implantable formulations of naltrexone may address this limitation and should be investigated for treatment of opioid dependence.
College of Physicians and Surgeons of Columbia University, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA. sulliva@pi.cpmc.columbia.edu
Maria A
MA
Sullivan
Fatima
F
Garawi
Adam
A
Bisaga
Sandra D
SD
Comer
Kenneth
K
Carpenter
Wilfrid N
WN
Raby
Stephen J
SJ
Anen
Adam C
AC
Brooks
Huiping
H
Jiang
Evaristo
E
Akerele
Edward V
EV
Nunes
D000328:Adult; D001521:Behavior Therapy; D003131:Combined Modality Therapy; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D005500:Follow-Up Studies; D006556:Heroin Dependence / Q000188:drug therapy* / Q000523:psychology*; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D009271:Naltrexone / Q000627:therapeutic use*; D009292:Narcotic Antagonists / Q000627:therapeutic use*; D010045:Outpatients; D012008:Recurrence; D013997:Time Factors
D009292:Narcotic Antagonists; D009271:Naltrexone