Gowing Linda, Ali Robert, White Jason M
Discipline of Pharmacology, University of Adelaide, Frome Road, Adelaide, South Australia, Australia, 5005.
Cochrane Database Syst Rev. 2009 Oct 7(4):CD002021. doi: 10.1002/14651858.CD002021.pub3.
Managed withdrawal is a necessary step prior to drug-free treatment or as the end point of long-term substitution treatment.
To assess the effectiveness of opioid antagonists in combination with minimal sedation to manage opioid withdrawal.
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966-July 2008), EMBASE (January 1985-2008 Week 31), PsycINFO (1967 to 7 August 2008) and reference lists of articles.
Controlled studies of interventions involving the use of opioid antagonists in combination with minimal sedation to manage withdrawal in opioid-dependent participants compared with other approaches or different opioid antagonist regimes.
One author assessed studies for inclusion and undertook data extraction. Inclusion decisions and the overall process were confirmed by consultation between all authors.
Nine studies (6 randomised controlled trials), involving 837 participants, met the inclusion criteria for the review.The quality of the evidence is low, but suggests that withdrawal induced by opioid antagonists in combination with an adrenergic agonist is more intense than withdrawal managed with clonidine or lofexidine alone, while the overall severity is less. Delirium may occur following the first dose of opioid antagonist, particularly with higher doses (> 25mg naltrexone).In some situations antagonist-induced withdrawal may be associated with significantly higher rates of completion of treatment, comp[ared to withdrawal managed primarily with adrenergic agonists. However, this outcome has not been produced consistently, and the extent of any benefit is highly uncertain.
AUTHORS' CONCLUSIONS: The use of opioid antagonists combined with alpha(2)-adrenergic agonists is a feasible approach to the management of opioid withdrawal. However, it is unclear whether this approach reduces the duration of withdrawal or facilitates transfer to naltrexone treatment to a greater extent than withdrawal managed primarily with an adrenergic agonist.A high level of monitoring and support is desirable for several hours following administration of opioid antagonists because of the possibility of vomiting, diarrhoea and delirium.Further research is required to confirm the relative effectiveness of antagonist-induced regimes, as well as variables influencing the severity of withdrawal, adverse effects, the most effective antagonist-based treatment regime, and approaches that might increase retention in subsequent naltrexone maintenance treatment.
在进行戒毒治疗之前或作为长期替代治疗的终点，有控制的脱毒是必要步骤。
评估阿片类拮抗剂联合最小剂量镇静用于管理阿片类药物脱毒的有效性。
我们检索了Cochrane对照试验中心注册库（《Cochrane图书馆》，2008年第3期）、MEDLINE（1966年1月至2008年7月）、EMBASE（1985年1月至2008年第31周）、PsycINFO（1967年至2008年8月7日）以及文章的参考文献列表。
对涉及使用阿片类拮抗剂联合最小剂量镇静来管理阿片类药物依赖者脱毒的干预措施进行对照研究，并与其他方法或不同的阿片类拮抗剂方案进行比较。
由一位作者评估纳入研究并进行数据提取。纳入决策和整个过程经所有作者协商确认。
9项研究（6项随机对照试验），涉及837名参与者，符合本综述的纳入标准。证据质量较低，但表明阿片类拮抗剂联合肾上腺素能激动剂诱导的脱毒比单独使用可乐定或洛非西定进行的脱毒更强烈，而总体严重程度较低。首次使用阿片类拮抗剂后可能会出现谵妄，尤其是使用较高剂量（>25mg纳曲酮）时。在某些情况下，与主要使用肾上腺素能激动剂进行的脱毒相比，拮抗剂诱导的脱毒可能与更高的治疗完成率相关。然而，这一结果并不一致，且任何益处的程度高度不确定。
使用阿片类拮抗剂联合α₂-肾上腺素能激动剂是管理阿片类药物脱毒的一种可行方法。然而，尚不清楚这种方法是否比主要使用肾上腺素能激动剂进行的脱毒能更大程度地缩短脱毒持续时间或促进向纳曲酮治疗的转换。由于可能出现呕吐、腹泻和谵妄，在使用阿片类拮抗剂后数小时需要进行高水平的监测和支持。需要进一步研究以确认拮抗剂诱导方案的相对有效性，以及影响脱毒严重程度、不良反应、最有效的基于拮抗剂的治疗方案以及可能增加后续纳曲酮维持治疗留存率的方法。
