The normal kidney responds to several (3 to 5) days of potassium depletion with appropri- depletion does not occur unless intake is ate renal potassium conservation order proscar now prostate cancer weight loss. In the absence of severe polyuria order cheap proscar on line mens health belly off, a “spot” urinary potassium well below 15 mEq of potassium per day cheapest proscar prostate cancer 3 months. Patients with acute m onocytic and m yelom onocytic leukem ias occasionally excrete large am ounts of lysozym e in their urine. Lysozym e appears to have a direct kaliuretic effect on the kidneys (by an undefined m echanism ). Penicillin in large doses acts as a poorly reabsorbable anion, resulting in obligate renal potassium wasting. M echanism s for renal potassium wasting associated with am inoglycosides and cisplatin are ill- defined. H ypokalem ia in type I renal tubular acidosis is due in part to secondary hyperaldosteronism , whereas type II renal tubular acidosis can result in a defect in potassium reabsorption in the proxim al nephrons. Carbonic anhydrase inhibitors result in an acquired form of renal tubular acidosis. The osm otic diure- sis associated with diabetic ketoacidosis FIGURE 3-9 results in potassium depletion, although Diagnostic approach to hypokalem ia: hypokalem ia due to renal losses with norm al acid- patients m ay initially present with a norm al base status or m etabolic acidosis. H ypokalem ia is occasionally observed during the diuret- serum potassium value, owing to altered ic recovery phase of acute tubular necrosis (ATN ) or after relief of acute obstructive transcellular potassium distribution. H ypokalem ia and m ag- nesium depletion can occur concurrently in a variety of clinical settings, including diuretic therapy, ketoacidosis, am inoglycoside therapy, and prolonged osm otic diuresis (as with poorly con- trolled diabetes m ellitus). H ypokalem ia is also a com m on finding in patients with congenital m agnesium -losing kidney disease. The patient depicted was treated with cisplatin 2 m onths before pre- sentation. Attem pts at oral and intravenous potassium replace- m ent of up to 80 m Eq/day were unsuccessful in correcting the hypokalem ia. O nce serum m agnesium was corrected, however, serum potassium quickly norm alized. The urine chloride value is helpful in distinguishing the causes of hypokalem ia. Diuretics are a com m on cause of hypokalem ia; however, after dis- continuing diuretics, urinary potassium and chloride m ay be appropriately low. Urine diuretic screens are warranted for patients suspected of surreptious diuretic abuse. Vom iting results in chloride and sodium depletion, hyperaldosteronism , and renal potassium wasting. Posthypercapnic states are often associated with chloride depletion (from diuretics) and sodium avidity. If hypercapnia is corrected without replacing chloride, patients develop chloride-deple- tion alkalosis and hypokalem ia. The hyperaldostero- nism and increased distal sodium delivery account for the characteristic hypokalem ic m etabolic alkalosis. M oreover, im paired sodium reabsorption in the TAL results in the hypercalciuria seen in these patients, as approxim ately 25% of filtered calcium is reabsorbed in this segm ent in a process coupled to sodium reabsorption. Since potassium levels in the TAL are m uch lower than levels of sodium or chloride, lum inal potassium concentrations are rate lim iting for N a+-K+-2Cl- co-transporter activity. Defects in ATP-sensitive potassium channels would be predicted to alter potassium recy- cling and dim inish N a+-K+-2Cl- cotrans- porter activity. Since approxim ately 30% of fil- m ore avid sodium and calcium reabsorption tered sodium is reabsorbed by this segm ent of the nephron, defective sodium reabsorption by the proxim al nephrons. FIGURE 3-14 CHARACTERISTICS OF HYPOKALEM IA W ITH Distinguishing characteristics of HYPERTENSION AND M ETABOLIC ALKALOSIS hypokalem ia associated with hypertension and m etabolic alkalosis. The am iloride- sensitive sodium channel on the apical m em brane of the distal tubule consists of hom ologous , , and subunits. Each subunit is com posed of two transm em brane-spanning dom ains, an extracel- lular loop, and intracellular am ino and carboxyl term inals. Truncation m utations of either the or subunit carboxyl term i- nal result in greatly increased sodium conductance, which creates a favorable electrochem ical gradient for potassium secretion. FIGURE 3-16 M echanism of hypokalem ia in the syndrom e of apparent m ineralo- corticoid excess (AM E). Cortisol and aldosterone have equal affini- ty for the intracellular m ineralocorticoid receptor (M R); however, in aldosterone-sensitive tissues such as the kidney, the enzym e 11 -hydroxysteroid dehydrogenase (11 -H SD) converts cortisol to cortisone. Since cortisone has a low affinity for the M R, the enzym e 11 -H SD serves to protect the kidney from the effects of glucocorticoids. In hereditary or acquired AM E, 11 -H SD is defective or is inactiveted (by licorice or carbenoxalone). Cortisol, which is present at concentrations approxim ately 1000-fold that of aldosterone, becom es a m ineralocorticoid. The hyperm ineralo- corticoid state results in increased transcription of subunits of the sodium channel and the N a+-K+-ATPase pum p. The favorable elec- trochem ical gradient then favors potassium secretion [7,15]. These enzymes have identical intron-extron structures and are closely linked on chromosome 8. The chimeric gene is now under the contol of ACTH, and aldosterone secretion is enhanced, thus causing hypokalemia and hypertension. By inhibiting pituitary release of ACTH, glucocorticoid administration leads to a fall in aldosterone levels and correction of the clinical and biochemical abnormalities of GRA. The presence of Aldo S activity in the FIGURE 3-17 zona fasciculata gives rise to characteristic ele- Genetics of glucocorticoid-remediable aldosteronism (GRA): schematic representation of vations in 18-oxidation products of cortisol unequal crossover in GRA. The genes for aldosterone synthase (Aldo S) and 11 -hydroxylase (18-hydroxycortisol and 18-oxocortisol), (11 -OHase) are normally expressed in separate zones of the adrenal cortex. Hypokalemia: Clinical M anifestations CLINICAL M ANIFESTATIONS OF HYPOKALEM IA Cardiovascular Renal/electrolyte Abnormal electrocardiogram Functional alterations Predisposition for digitalis toxicity Decreased glomerular filtration rate Atrial ventricular arrhythmias Decreased renal blood flow Hypertension Renal concentrating defect Neuromuscular Increased renal ammonia production Smooth muscle Chloride wasting Constipation/ileus Metabolic alkalosis Bladder dysfunction Hypercalciuria Skeletal muscle Phosphaturia W eakness/cramps Structural alterations Tetany Dilation and vacuolization of Paralysis proximal tubules Myalgias/rhabdomyolysis Medullary cyst formation Interstitial nephritis Endocrine/metabolic Decreased insulin secretion Carbohydrate intolerance Increased renin FIGURE 3-19 Decreased aldosterone Electrocardiographic changes associated with hypokalemia. A, The Altered prostaglandin synthesis U wave may be a normal finding and is not specific for hypokalemia. Growth retardation B, W hen the amplitude of the U wave exceeds that of the T wave, hypokalemia may be present. The QT interval may appear to be prolonged; however, this is often due to mistaking the QU interval for the QT interval, as the latter does not change in duration with FIGURE 3-18 hypokalemia. C, Sagging of the ST segment, flattening of the T wave, and a prominent U wave are seen with progressive hypokalemia. D, The QRS complex may widen slightly, and the PR interval is often prolonged with severe hypokalemia. Hypokalemia promotes the appearance of supraventricular and ventricular ectopic rhythms, especially in patients taking digitalis. The predom inant pathologic finding accom pa- nying potassium depletion in hum ans is vacuolization of the epithelium of the proxim al convoluted tubules. The vacoules are large and coarse, and staining for lipids is usually negative.

This study was hampered by the lack tomography (PET) have shown that regional activation of of a valid and reliable scale to measure poor insight and by the prefrontal cortex varies according to factor (69) generic proscar 5 mg without a prescription prostate cancer herbal treatment, and the retrospective assessment of the course order proscar cheap online prostate cancer trials. We have recently emerging genetic data suggest that familial loading varies published data on the reliability and validity of a new scale buy 5mg proscar fast delivery prostate cancer journal articles, according to factor (70). Symmetry and certain obsessions, the Brown Assessment of Beliefs Scale (BABS), that has such as aggressive and sexual obsessions, are more frequent demonstrated excellent sensitivity to change with short-term in patients with OCDand chronic tics (71). The phase of a double-blinded relapse study of sertraline in analytic technique used to identify factors from the Y-BOC OCD. They found no significant correlation between de- Symptom Checklist may be fruitful in predicting the course gree of insight as measured by the BABS and outcome after of OCD. Evidence is increasing that patients in whom 16 weeks of sertraline. The role of insight in remission and hoarding is a primary obsessive-compulsive symptom are relapse deserves further scrutiny. In addition, hoarding was the only com- tions in neurologic function involving the basal ganglia after pulsion associated with a lower probability of remission in head trauma, encephalitis, and birth events (62). In a number of studies, an earlier age psychological abnormalities in comparison with a control at onset of OCDwas associated with a worse prognosis. Thomsen (36) reported that attainment ceiver operating characteristic analysis found that a cutoff of puberty by the time of referral predicted a better prog- of three or more signs yielded the minimum number of nosis than a prepubertal onset. In a reanalysis of the multi- combined errors of sensitivity and specificity in blindly dis- center efficacy and safety data for clomipramine, Ackerman tinguishing OCDsubjects from controls. A second study of OCDadolescents for confounds, found a later age at onset to be a strong found a high frequency of age-inappropriate synkinesias and predictor of response. Skoog and Skoog (42) reported that lateralization of deficits to the left side of the body (64). In onset of OCDbefore age 20 was related to a poorer out- a nonblinded study in which a clinical neurologic examina- come, especially in men. In other studies, age at onset did tion was performed in childhood and adolescent OCDsub- not predict severity of illness at follow-up. Adolescents in jects, most of the patients had abnormal neurologic find- the study of Berg et al. It seems likely sided signs that were suggestive of right-sided dysfunction. However, in the only study we could locate that type in OCD. Thus far, specific obsessions and compulsions have not predicted outcome in the vast majority of follow- examined level of functioning in OCD, pretreatment func- up studies. In a preliminary analysis of 544 patients from tioning did not predict follow-up outcome (73). Duration a multicenter trial of acute clomipramine, the authors failed of symptoms was not predictive in any study (78,79,81, to find any significant correlation between symptom sub- 82), although it is possible that chronicity accompanied by type, identified by the Y-BOC Symptom Checklist, and comorbidity may worsen prognosis. However, STABILITY OVER TIME few systematic clinical psychopathologic studies had been completed before 1985. Earlier studies were retrospective The beginning clinician is often struck by the diversity of and failed to utilize standardized diagnostic criteria or relia- the clinical presentations of OCD. During the last 15 years, we have character- ters on whether a psychopathologic continuum exists for ized the phenomenologic and clinical features of more than the two disorders. Some investigators have suggested that 1,000 patients with OCD. The basic types and frequencies obsessions are a preliminary sign of schizophrenia, whereas of obsessive-compulsive symptoms have been found to be others have claimed that obsessional thoughts are a neurotic consistent across cultures and time (84). Why particular defense against psychotic decompensation. Most current re- symptom patterns develop in given persons remains un- searchers feel that the two disorders are different entities known. The most common obsessions include contamina- without any true relationship. If OCDwas closely related to tion, pathologic doubt, aggressive and sexual thoughts, so- schizophrenia, one would expect that schizophrenia would matic concerns, and the need for symmetry and precision. How- The most common rituals are checking, cleaning, and ever, follow-up studies have shown that the incidence of counting. Rosen (85), in a retrospective terms of variation in overall intensity of symptoms, finer chart review of 850 inpatients with schizophrenia, found analyses of variations in symptom focus or symptom mix that approximately 10% exhibited prominent obsessive- have not been attempted. Nevertheless, in their study of compulsive symptoms. This finding was replicated by childhood OCD, Swedo and Leonard (22) reported that Fenton and McGlashan (86), who found that 10% of 90% of patients experienced some change in symptom pat- schizophrenics in a Chestnut Lodge (Rockville, Maryland) tern over time, often starting with a solitary ritual without follow-up study exhibited prominent obsessive-compulsive associated obsessive thoughts (notably uncommon in symptoms. These obsessive-compulsive schizophrenic pa- adults), then later adding new symptoms that sometimes tients tended to have a more chronic course and a greater became predominant over earlier ones. More work is needed frequency of social or occupational impairment in compari- to delineate the frequency and magnitude of the cyclic varia- son with a matched sample of schizophrenics without obses- tions in intensity and focus of obsessive-compulsive symp- sive-compulsive features. The average Y-BOCS score for those meeting the criteria COMORBIDITY for OCDwas 22. The relationship between obsessions, compulsions, and Biological markers and neuropharmacologic challenge stud- depression was the subject of several early studies. These ies depend on the selection of homogeneous clinical popula- were primarily retrospective and failed to use diagnostic cri- tions that reduce the variance. In studying a disorder like teria or structured interviewing. Thus, many aspects of the OCD, the presence of other axis I disorders is a serious association between depression and OCDremain unclear. The majority (57%) of OCDpatients present- tive episodes in OCDare primary or secondary. Dividing ing to our clinic have at least one other DSM-III-R diagno- depressed obsessional patients into these two categories (i. To complicate matters further, OCDis a chronic illness, primary and secondary) was originally advocated by Lewis and an even higher percentage of our patients have a lifetime (24). No systematic study of the frequency of obsessions history of another axis I disorder. Distinguishing primary and compulsions in a sample of depressed patients existed from secondary diagnoses can often be difficult, if not im- until recently. Although a great deal of interest has been possible. The coexistence of other anxiety states, depression, It has been noted that obsessive-compulsive features are and psychotic symptoms with obsessive-compulsive symp- rarely, if ever, seen in mania. We reported a case of OCD Chapter 111: Obsessive-Compulsive Disorder 1603 in a patient with bipolar disorder whose obsessions and childhood. Videbach (92) observed the same in 52 (50%) compulsions worsened in direct proportion to the severity of his 104 depressed, ruminative patients. Similarly, Ingram of his depression and totally disappeared when he became (26) reported that 22 (25%) of 89 OCDpatients had had manic (89). Although preliminary evidence suggests that significant phobias in childhood.

Last modified: November cheap proscar 5mg with amex prostate cancer color, 2017 13 HAMILTON DEPRESSION RATING SCALE Many different scales are used in the assessment of depression buy proscar 5 mg amex androgen hormone synthesis. The Hamilton Depression Rating Scale (HDRS purchase generic proscar canada mens health 032013, or HAM-D (D for depression); Hamilton also created an anxiety scale) has been widely used for more than 5 decades (Hamilton, 1960). The HDRS is not used to make a diagnosis, but to rate severity. A diagnosis must be made before the HDRS is applied. Serial ratings over time reflect change (hopefully, improvement). Because it relies on many vegetative symptoms, the HDRS is not applicable when there is a concurrent severe medical disorder. The original HDRS consisted of 21 items, however, shorter versions are available. Even though the HDRS is not used for diagnosis, many researchers have come to equate the 17-item score of 8, and the 6-item score of 4 with remission. To ensure subjects have at least moderate depression, many studies require a 17-item entry score 18. A COPY OF THE HDRS FOLLOWS THE REFERENCES MONTGOMERY ASBERG DEPRESSION RATING SCALE The Montgomery Asberg Depression Rating Scale (MADRS; Montgomery & Asberg 1979) is another important depression scale. It followed almost two decades after the HDRS, but has been widely used over the last quarter of a century. In contrast to the HDRS, the MADRS is less strongly focused on the somatic symptoms of depression, and more strongly on items such as concentration difficulties, tension, lassitude, pessimistic and suicidal thoughts. The initial hope was that being less focused on somatic symptoms, the MADRS would be more sensitive to change than the HDRS. COPIES OF THE HDRS AND MADRS FOLLOW THE REFERENCES Pridmore S. Last modified: November, 2017 14 References Afridi M, Hima M, Qureshi I, Hussain M. Cognitive disturbance among drug-naïve depressed cases and healthy controls. Repetitive transcranial magnetic stimulation for treatment resistant depression: re-establishing connections. Clinical Neurophysiology 2016; 127: 33943405 Andrews G, Poulton R, Skoog I. Lifetime risk of depression: restricted to a minority or waiting for most? Vitamin D deficiency and depression in adults: a systematic review and meta-analysis. Functional connectivity of the left DLPFC to striatum predicts treatment response of depression to TMS. Meta-analysis of magnetic resonance imaging studies of the corpus callosum in bipolar disorder. Acta Psychiatrica Scandinavica 2008; July 17 [Epub ahead of print]. Role of neuro-immunological factors in the pathophysiology of mood disorders. Psychopharmacology 2016 [Epub ahead of print] Becking K, Spijker A, Hoencamp E, et al. Disturbances in hypothalamic-pituitary- adrenal axis and immunological activity differentiating between unipolar and bipolar depressive episodes. Major depression: does a gender-based down-rating of suicide risk challenge its diagnostic validity? Australian and New Zealand Journal of Psychiatry 2001; 35:322-328. A debate on their efficacy for the treatment of major depression. Expert Rev Neurother 2016 [Epub ahead of print] Butterworth P, Fairweather A, Anstey K, Windsor T. Hopelessness, demoralization and suicidal behaviour: the backdrop to welfare reform in Australia. Australian and New Zealand Journal of Psychiatry 2006; 40:648-656. The role of brain structure and function in the association between inflammation and depressive symptoms: a systematic review. Lower hippocampal volume in patients suffering from depression: a meta-analysis. Clarke D, Mackinnon A, Smith G, McKenzie D, Herman H. Australian and New Zealand Journal of Psychiatry 2002; 36:733-742. Resting-state connectivity predictors of response to psychotherapy in major depressive disorder. Efficacy of cognitive-behavioral therapy and other psychological treatments for adult depression: meta-analytic study of publication bias. Neuropsychological symptom dimensions in bipolar disorder and schizophrenia. The subgenual anterior cingulate cortex in mood disorders. Last modified: November, 2017 15 De Figueiredo J, Gostoli S. Recent developments and current controversies in depression. Mentalizing in female inpatients with major depressive disorder. Journal of Nervous and Mental Disease 2013, in press. A morphometric study of glia and neurons in the anterior cingulate cortex in mood disorder. Differentiating unipolar and bipolar depression by alterations in large-scale brain networks. Gutkovich Z, Rosenthal R, Galynker I, Muran C, Batchelder S, Itskhoki E. Depression and demoralization among Russian-Jewish immigrants in primary care. Journal of Neurology, Neurosurgery and Psychiatry 1960; 23:56-62. An examination of the sensitivity of the six-item Hamilton Rating Scale for Depression in a sample of patients suffering from major depressive disorder. The Loss of Sadness: How psychiatry transformed normal sorrow into depressive disorder.

It was mentioned earlier as a detoxification istration if illicit drug use or diversion is detected order 5mg proscar mens health eating plan, random agent and is discussed later and in more detail because it urine testing order 5mg proscar mastercard prostate nodule, and call-back procedures in which patients has unique properties that are likely to result in its being will be required to report to the medical treatment setting used with fewer regulatory controls than methadone and and to produce the remaining discount proscar 5 mg otc mens health 28 day abs, unused take-home con- LAAM. Both methadone and LAAM are Schedule II controlled The appropriate agonist medication dosage has been a substances and can be used only for maintenance and detox- subject of both federal and state regulations, although there ification in programs that are licensed and regulated by the has been a gradual shift toward allowing more clinical judg- FDA and the Drug Enforcement Administration (DEA). Numerous studies have been The regulations specify who is eligible for treatment, proce- conducted since the mid-1970s to determine the optimal dures that are required for its administration, the number dose, and, although it is clear that some patients do well of take-home doses permitted, and the type of medication on low doses of methadone or LAAM (about 20 to 50 mg), storage security needed. Treatment programs have been in- studies have consistently shown that most patients need spected approximately every 3 years for the past 30 years, higher doses if they are to achieve maximum benefit from and violations have resulted in sanctions ranging from ad- agonist treatment (25). The results of these methadone dose ministrative citations to criminal prosecution. Clinics are clinical response have not been observed consistently. One often located in old buildings that have been converted to study found significant correlations between oral dose and comply with regulations but that were never intended for methadone concentration, but only among patients who medical use. At the present time, it is estimated that approxi- complained of low dosing (26). These findings suggest that mately 179,000 patients are being maintained on metha- some patients may be more sensitive to dosage changes and done or LAAM at 940 or more sites, and this number repre- that clinical response, including subjective complaints, is a sents only about 20% of the opioid addicts in the United more important guide to adequate dose levels than specific States (21). No controlled studies have been done examin- This treatment-program regulatory system has been ing doses higher than 120 mg; thus, the upper limits of under increasing criticism since the early 1990s. Criticism dosing effectiveness are not well understood. The importance approved for detoxification or maintenance that are in of these criticisms has been underlined by the recent increase Schedules III, IV, and V (27). Physicians who choose to in heroin addiction (22), by evidence that methadone main- treat persons with opioid dependence under the new regula- tenance reduces the incidence of hepatitis and HIV infec- tions will need to notify the Secretary of Health and Human tion, and by the lack of coverage for agonist maintenance Services in writing of their intent and to show that they 1510 Neuropsychopharmacology: The Fifth Generation of Progress are qualified to provide addiction treatment by virtue of prenorphine for its own positive subjective effects (33,34). No physician would be allowed Only one study published to date has characterized the be- to treat more than 30 patients at one time without special havioral and physiologic effects of a wide range of buprenor- approval, according to the legislation as it is now proposed. The re- This change in the regulations will be especially impor- sults indicated that buprenorphine, given intravenously, has tant for buprenorphine and the buprenorphine-naloxone a low abuse liability in this population. The to be treated in the current methadone or LAAM system. Parenteral misuse of of medical care, to make it more readily available, and to the combination by persons addicted to opioids would be improve its quality. Buprenorphine is marketed internationally as an combination product in an office-based setting represents analgesic (both without naloxone and with naloxone to an innovative alternative to the restrictive methadone or deter abuse) and as a treatment for opioid addiction. The most widespread use of buprenorphine is in France, where use of this new drug combination should expand the avail- it was approved for the latter indication in 1996. In the ability of agonist maintenance treatment with a relatively United States, buprenorphine is currently approved only low risk for abuse or diversion. In addition, the partial ago- as an analgesic for parenteral administration; approval for nist activity of buprenorphine results in a much lower risk of opioid addiction treatment is pending. Buprenorphine has overdose death than is the case with methadone or LAAM. Most of the Antagonist Maintenance early clinical trials used a sublingual solution of buprenor- phine formulated in a hydroethanolic vehicle, although a Naltrexone is the prototypical opioid antagonist used in more commercially suitable sublingual tablet formulation abstinence maintenance therapy; this drug blocks the effects is now used. Naltrexone has no opioid agonist effects and is full agonists such as methadone and LAAM is the plateau a competitive opioid antagonist. It is orally effective and effect of -agonist activity. Parenteral doses as high as 12 can block opioid effects for 24 hours when administered as mg intravenously (28) have been given to opioid-intolerant a single daily dose of 50 to 60 mg. Higher doses usually patients with only limited adverse effects (e. Numerous large trials have con- they will provide more cross tolerance to heroin and other firmed the utility of buprenorphine for agonist maintenance opioids during the 24-hour dosing period (38). These studies have included comparisons of bu- favorable adverse event profile (nausea is typically the most prenorphine with placebo (29,30), a buprenorphine-nalox- common side effect), naltrexone is generally not favored by one combination with placebo (30), and a multiple-dose opioid addicts because, unlike opioid agonists and partial comparison study (31). In one of the most recent trials (32), agonists, it produces no positive, reinforcing effects. Fur- buprenorphine (given three times weekly) was compared thermore, it may be associated with the precipitation of an with LAAM (given three times weekly) and methadone opioid withdrawal syndrome if it is used too soon after (given daily) in a 17-week study. Mean retention in treat- opioid use stops, an effect that can be minimized by admin- ment was higher for buprenorphine, LAAM, and high-dose istering a naloxone challenge test before giving naltrexone. Opioid- more than 25 years, work continues on increasing medica- positive urine samples decreased most for the LAAM-treated tion compliance and improving outcomes. Some of these group and least for low-dose methadone. Patient self-reports more recent efforts include work to develop a depot form of opioid use did not differ among the groups, but they that will block opioid effects for 14 to 28 days. This dosage showed decreases of about 90% over the course of the study. At present, a Buprenorphine has the potential to be abused and can patient treated with naltrexone has only to stop the medica- produce addiction. However, most persons who abuse bu- tion for 1 to 3 days to experience the full effects of subse- prenorphine initiated opioid use with other drugs. A depot dosage form of naltrexone would may take the form of using greater than prescribed dosages provide more time for patients to overcome ambivalence for analgesia, using buprenorphine in place of a more de- about stopping opioid use and could result in more long- sired but less available opioid such as heroin, or using bu- term success than has currently been the case. Another var- Chapter 105: Treatment of Opioid Addiction 1511 iant on antagonist treatment is nalmefene, an orally effective weeks or months of treatment with reductions in frequency but somewhat longer-acting (about 48 hours at dosages of to biweekly or monthly depending on progress. Results showed a dence and abuse are ambivalent about stopping drug use dose–response relationship with the minimal condition (41,42). This ambivalence presents a therapeutic challenge doing significantly worse than standard and enhanced coun- because it contributes to varying levels of motivation to seling doing the best overall; however, about 30% of pa- enter and remain in treatment, to early dropout, and to tients did well in the minimal counseling condition. This partial or (in some cases) nontreatment response. Studies study clearly demonstrated the positive benefits achieved by have emphasized that treatment providers must be aware of drug counseling and showed that, for most patients, coun- this 'normal' ambivalence and make reasonable efforts to seling is necessary to bring out the maximum benefits of resolve it in favor of treatment participation and cessation agonist maintenance. Suggestions have been made regarding Most counseling is individual, one on one, but some initial steps to maximize the chances for engagement in programs use group therapy exclusively. These include avoiding programs use groups only for selected patients with focal unnecessary delays in entering treatment, expressing a hope- problems such as HIV disease, posttraumatic stress disorder, ful and nonjudgmental attitude, performing a comprehen- homelessness, loss of close personal relationships, or not at sive evaluation, and developing a treatment plan that is re- all. Some programs have self-help groups or with medical, psychiatric, legal, employment, and family that meet regularly on site. Counselors, like psychothera- or social issues that preexist or result from the addiction. This Research has found that addressing these additional prob- variability seems more related to the ability to form a posi- lems can be helpful, but they are complex and require coor- tive, helping relationship with the patient than to specific dination between agonist pharmacotherapy staff and other techniques (46). Contingency management techniques are always in- The most common type of psychosocial service in opioid cluded in drug counseling, if for nothing else than to fulfill agonist treatment is individual drug counseling. Counselors regulations about requiring progress in treatment as a condi- are typically persons at the masters level or below who de- tion of providing take-home doses, and studies have shown liver a behaviorally focused treatment aimed to identify spe- that they can be very helpful. For example, an opportunity cific problems, to help the patient access services that may to receive take-home medications in return for drug-free not be provided in the clinic (e.

A. Sibur-Narad. Southern Wesleyan University.