8/7/2019 Narcotic Antagonist Treatment of Addict Parolees by Dr. Charles Savage http://slidepdf.com/reader/full/narcotic-antagonist-treatment-of-addict-parolees-by-dr-charles-savage 1/9 Narcotic Antagonist Treatment of Addict Parolees- The Failure of an Effective Approach Thomas E. Hanlon, 0. Lee McCabe, Charles Savage, and Albert A. Kurland C ONTEMPORARY TREATMENT APPROACHES for the chronic nar- cotic abuser may be subsumed under two major models: maintenance and abstinence. Prototypes of the maintenance model are the “British system” of le- galized narcotics prescription and the “American system” of daily methadone administration. Included under the abstinence model are various procedures aimed at eliminating drug-seeking behavior and, ironically, establishing the goal of treatment, i.e., abstinence, as a condition of continued participation from the very outset. Procedures used in attempts at achieving the abstinence goal range from traditional and behavior therapy to more exotic methods such as transcendental meditation. One of the more recently applied abstinence methods is the narcotic antagonist approach, the rationaleof which is anchored in learning theory/behavior modifica- tion principles implemented through the use of a chemical agent. The apparently sound theoretical basis for the application of this approach, together with promis- ing early clinical trials, have produced not only an unusual amount of enthusiasm and activity among scientists and clinicians in the tield but also a corresponding supportive commitment from the United States Federal Government. The massive expenditures of time, effort, and money to date not withstanding, there are still unsettling questions which need to be answered before generalizations about the efficacy of available narcotic antagonists can be made. In fact, our own previous work with these substances, as well as the pioneering effor ts of other investigators, have raised as many questions as they have answered. Issues which appear to be of special relevance are the following: a) What spe- cific therapeutic actions do antagonists have when placebo and programmatic ele- ments are controlled? b) Must antagonists be administered daily, or can they be effectively utilized on a “crisis-intervention” basis? c) Do so-called “pure” an- tagonists such as naloxone have any significant side effects; particularly those which might bias outcome in favor of patients not receiving active medication’? d) On the other hand, are some secondary effects remedial, i.e., might not the best antagonist be one with a slight agonistic property of its own? e) Do some types of addicts respond better to antagonist treatment than others? f) Is antagonist treat- ment uniformly effective over diverse outcome criteria’? From the Maryland Psychiarric Research Center and rhe V:! Hospital. Baltimore. Md. Thomas E. Hanlon, Ph.D.: ChieJ’o/ Socioenvironmenral Research. and 0. Lee McCabe. Ph.D.: Chief’?/ .4ddkrions Research, Maryland Psychiatric Research C‘enier, Charles Savage, M.D.: Chiei oJ Psychiatric and Chiej’oj the Drug Dependenre Treatment L/nits. If.3 Hospital. Albert A. Kurland. M.D.: Superintendent, Maryland Psychiatric Research Center. allof Baltimore. Md. 21228. Supported by the Division of Research. National tnsfirure on Drug .4buse, NID.4 Grani D.3004IC. and the Drug .4 buse .Administration oJlheSlatt,o/‘Mar~land. Reprint requessrs should be addressed to Thomas E. Ha&on. Maryland P.yychiarric Reseawh Center, Baltimore. Md. 21228. L 1977 bv Grune & Strarron. Inc. Comprehensive Psych/atry, Vol 18, No. 3 (May/June) 1977 21 1
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8/7/2019 Narcotic Antagonist Treatment of Addict Parolees by Dr. Charles Savage
Thomas E. Hanlon, 0. Lee McCabe, Charles Savage, and Albert A. Kurland
CONTEMPORARY TREATMENT APPROACHES for the chronic nar-
cotic abuser may be subsumed under two major models: maintenance and
abstinence. Prototypes of the maintenance model are the “British system” of le-
galized narcotics prescription and the “American system” of daily methadone
administration. Included under the abstinence model are various procedures
aimed at eliminating drug-seeking behavior and, ironically, establishing the goal of
treatment, i.e., abstinence, as a condition of continued participation from the very
outset. Procedures used in attempts at achieving the abstinence goal range from
traditional and behavior therapy to more exotic methods such as transcendental
meditation.One of the more recently applied abstinence methods is the narcotic antagonist
approach, the rationaleof which is anchored in learning theory/behavior modifica-
tion principles implemented through the use of a chemical agent. The apparently
sound theoretical basis for the application of this approach, together with promis-
ing early clinical trials, have produced not only an unusual amount of enthusiasm
and activity among scientists and clinicians in the tield but also a corresponding
supportive commitment from the United States Federal Government. The
massive expenditures of time, effort, and money to date not withstanding, there
are still unsettling questions which need to be answered before generalizations
about the efficacy of available narcotic antagonists can be made. In fact, our ownprevious work with these substances, as well as the pioneering efforts of other
investigators, have raised as many questions as they have answered.
Issues which appear to be of special relevance are the following: a) What spe-
cific therapeutic actions do antagonists have when placebo and programmatic ele-
ments are controlled? b) Must antagonists be administered daily, or can they be
effectively utilized on a “crisis-intervention” basis? c) Do so-called “pure” an-
tagonists such as naloxone have any significant side effects; particularly those
which might bias outcome in favor of patients not receiving active medication’? d)
On the other hand, are some secondary effects remedial, i.e., might not the best
antagonist be one with a slight agonistic property of its own? e) Do some types ofaddicts respond better to antagonist treatment than others? f) Is antagonist treat-
ment uniformly effective over diverse outcome criteria’?
From the Maryland Psychiarric Research Center and rhe V:! Hospital. Baltimore. Md.
Thomas E. Hanlon, Ph.D.: ChieJ’o/ Socioenvironmenral Research. and 0. Lee McCabe. Ph.D.:
Chief’?/ .4ddkrions Research, Maryland Psychiatric Research C‘enier, Charles Savage, M.D.: Chiei
oJ Psychiatric and Chiej’oj the Drug Dependenre Treatment L/nits. If.3 Hospital. Albert A. Kurland.
M.D.: Superintendent, Maryland Psychiatric Research Center. allof Baltimore. Md. 21228.
Supported by the Division of Research. National tnsfirure on Drug .4buse, NID.4 Grani D.3004IC.
and the Drug .4 buse .Administration oJlheSlatt,o/‘Mar~land.
Reprint requessrs should be addressed to Thomas E. Ha&on. Maryland P.yychiarric Reseawh
Addressing itself to many of the above issues, the present study is the latest in a
series of studies on the effectiveness of narcotic antagonists in the treatment of
narcotic addict parolees newly released from the Maryland correctional system toa narcotic clinic in metropolitan Baltimore. It is the concluding report on the
“contingent” approach to the use of antagonists in this setting, offering a sum-
marization of all of our experiences to date.
The overall program of research, which was superimposed on an ongoing ab-
stinence program,’ started several years ago with the introduction of the promis-
ing agent, naloxone (N-allylnoroxymorphone), a pure antagonist relatively free of
side effects. The scarcity and expense of naloxone at the time and the natural
reluctance on the part of most parolees to take medication daily prior to the
manifestation of need made the administration of naloxone contingent upon nar-
cotic drug use seem both economical and clinically appropriate. Early clinicalexperiences and subsequent pilot research2-4 were encouraging enough to prompt
a series of controlled clinical trials, the latest of which is herein reported.
MATERIALS AND METHODS’
Having volunteered for a six month narcotic antagonist treatment program, 154 newly paroled male
narcotic addicts were referred to an abstinence clinic employing daily urine monitoring and offering
weekly group psychotherapy. Upon referral, the parolees were randomly assigned to either a naloxone
or placebo treatment group and were administered medication under double-blind conditions whenever
unexcused absences or urinalysis results were indicative of opiate drug use. Ranging from l-4 tablets
per day, the equivalent of 500~2000 mg of naloxone, dosage was escalated on a one tablet per day basis
with continued evidence of opiate drug use and was discontinued only after four successive negativeurine specimens were obtained. Throughout the six month period, this procedure was repeated with
each subsequent deviation.
Criteria of treatment effectiveness included the number of unexcused absences, the number of
opiate positive specimens, length of participation in the program, reasons for termination, type and in-
cidence of side effects, and global community adjustment ratings for those remaining on the program
for the entire 6 months. The Minnesota Multiphusic Personality Inventory (MMPI) was administered
initial ly for descriptive and predictive purposes. Although its use as a criterion measure was curtailed
by lack of adequate group representation, the MMPI was also administered to study remainers at the
6 month evaluation point.
RESULTS
Of the 154 parolees referred to the study and assigned to the two treatment
conditions, 57 did not receive study medication for one reason or another and were
necessarily excluded from the naloxone-placebo comparison. Thirty-three of the
57 nonmedicated parolees completed the prescribed six month abstinence
program without a deviation in terms of unexcused absences or a positive urine
specimen. The remaining 24 nonmedicated parolees either refused medication or
absconded prior to the reception of medication.
Resulting sample sizes of parolees receiving medication were 55 for naloxone
and 42 for placebo. Descriptive characteristics for these parolees are presented in
Table 1.
Considering the total study sample of 97 parolees, the typical parolee was
single, black, in his mid twenty’s, and had completed a junior high school level of
education. He had experienced his first documented encounter with the law
enforcement system at age 17 and was subsequently involved in an average of four
more arrests, largely for drug-related reasons. The two subsamples showed no
8/7/2019 Narcotic Antagonist Treatment of Addict Parolees by Dr. Charles Savage
Table 1. Demographic Characteristics of the Two Subsamples
Charactenstxs
Mean Age
Race
Black
White
Marital Status
Single
Married
Separated/Divorced
Mean Years of Education
Mean Age at First Arrest
Mean Number of Arrests
Naloxone PIWhO
Group GroupN = 55 N = 42
266 26.0
54 38
1 4
43 32
7 6
5 4
92 90
173 164
52 5.9
substantial differences with respect to the demographic characteristics in ques-
tion.
The MMPI profile for the study sample was similar in most respects to that
offered by Overall” as being the prototype for narcotic addicts. Its most salient
feature was the 4-9 ‘code type,’ considered by Marks and Seeman to be indica-
tive of a sociopathic-emotionally unstable personality with a high probability of
drug usage or addiction, and by Gilberstadt and Duker’ as characteristic of indi-
viduals who, though superficially friendly, outgoing, and likeable, tend to be self-centered, impulsive, and rebellious and to have a low standard of morality. The
initial MMPI profiles for the two subsamples are presented in Fig. 1. Although
there were no statistically significant differences between group means for any of
the validity or clinical scales shown, the overall profile for the placebo group
tended to have a slightly higher elevation. Completion and termination data for
the two subsamples and for the total sample are presented in Table 2.
The chi square value for the seemingly differential completion rate in favor of
placebo noted in the table was found to be 3.27 (3.84 needed for significance at the
0.05 level for 1 df). Considering the reasons for termination, this rate must be
viewed as a negative rather than a positive reflection of the pharmacological action
-- Nalorone
- PkWhO
100
90
Fig. 1. In i t i a l MMPI prof i les for the Naloxone (N =
43) and Placebo (N = 38) subsamples.
L F Kti5 DH~WMIP~P~SCM~S,
MMPI SCALES
8/7/2019 Narcotic Antagonist Treatment of Addict Parolees by Dr. Charles Savage
Table 2. Completion and Termination Data for the Total and Two Subsamples
Disposition
Completed
Terminated
Absconded
Refused Further
Medication
Institutionalized
Transferred to
Maintenance
NSlOXO” e Placebo
Group Group
N = 55 N = 42
20 (36%) 23 (55%)
35 (64%) 19 (45%)
11 (20%) 7 (17%)
16 (29%) 8 (19%)
7 (13%) 1 (2%)
1 (2%) 3 (7%)
Total
Sample
N = 97
43 (44%)
54 (56%)
18 (19%)
24 (25%)
8 (8%)
4 (4%)
of naloxone, including, ironically, its antagonistic effect. Data relating to thelength of program participation are consistent with completion rates. The average
length of participation for the naloxone group was found to be 3.7 months vs. 4.8
months for the placebo group, most of this one month differential being accounted
for by the shorter participation of naloxone patients once medication was begun.
Results of urine monitoring procedures, in terms of unauthorized absences and
the provision of either a QNS or opiate positive urine specimen, are presented in
Table 3. Since the results of such procedures prior to the reception of medication
were uninfluenced by specific treatment effects, only data occurring after the
initiation of treatment were examined for comparative purposes. Also, to insure
meaningfulness of the information involved, only those individuals who remainedin the program for at least one month after their first dosage reception were in-
cluded in the analysis of results. Comprising at least 75% of their respective sam-
ples, 41 naloxone and 37 placebo subjects were thus selected.
Again reflecting the relative retention rates of the two treatments, those
parolees receiving placebo tended to remain longer in treatment and to attend the
clinic, providing an analyzable urine specimen, at least as reliably as those receiv-
ing naloxone. They were, however, providing positive urine specimens at a signifi-
cantly higher rate (the proportional difference of 0.11 vs. 0.07 significant at p <
.OOl). This result was largely accounted for by eight placebo cases whose rates
were above that of 39%, the highest for the naloxone group, and was consistentwith earlier reported findings of the relative effects of daily administered naloxone
vs. placebo.8
In view of the causal relationship involved, the amount of medication dispensed
in the contingent approach can be considered as another indication of the extent of
narcotic drug use, i.e., the greater amount, the greater the narcotics use. On the
average, treatment for both the naloxone and placebo groups was begun shortly
after one month of abstinence program participation. Although there was an
Table 3. Resultsof Urine Monitoring Procedures After the Initiation of Medication
Group
Numberof
Days Active
PercentageofUnexcused
Absences and
ONS Specimens
Number ofAnalyzable
Specimens
Provided
Percentageof Positive
Specimens
Percentageofuncoopara-
tive
Days
Naloxone (N = 41)
Placebo (N = 37)-
98 21% 73 7% 25%
114 22% 90 11% 27%
8/7/2019 Narcotic Antagonist Treatment of Addict Parolees by Dr. Charles Savage
average of three contingent interventions for both treatment groups, the mean
number of days medication was dispensed overall was 19 days for naloxone and 25
days for placebo, with average daily dosages being 757 mg and the equivalent of
1068 mg, respectively (total mg dispensed/total days of administration). Analysis
of individual dosage schedules revealed that patients administered naloxone
tended to moderate their narcotic drug intake when they were placed on the
maximum dosage of 2000 mg. Whereas approximately one-third of the patients in
both treatment groups were administered the maximum dosage at one time or
another during the course of treatment, the average number of days this dosage
was utilized in the treatment of these cases was only 5 days for naloxone vs. 22
days for placebo. This result was not explainable in terms of relative absence or
dropout rates since these were found to be equivalent in the two treatment groups
at the 2000 mg level.
Of the 43 patients completing the prescribed treatment course, data on a locally
devised community adjustment scale” were available for 36 patients, or 18 from
each of the two treatment groups. Consisting of an average of IO-point ratings of
abstinence and occupational, residential and interpersonal adjustment, this scale
was completed by a social worker after an interview with the parole agent
responsible for the supervision of the addict in the community. As in earlier
studies in the same setting, the mean adjustment rating for the total sample of
study completers at six months was approximately 7.0, indicative of “good overall
adjustment,” with at least half of the sample demonstrating either no, or only
slight (“chipping”), narcotic drug use. Mean adjustment ratings for the naloxone
and placebo subsamples were almost identical.
Side effect information was also in agreement with past experiences with na-
loxone. Somatic complaints were reported for a total of 26 patients, 16 of whom
were receiving naloxone and 10 placebo. Accounting for the only significant
difference in terms of side effects between drug or placebo, gastrointestinal
distress (nausea, vomiting, and/or upset stomach) occurred in ten naloxone cases
vs. only one placebo case. Although severe untoward reactions necessitating the
termination of treatment did not occur, two naloxone patients refused further
medication after experiencing gastrointestinal problems and one after
unelaborated complaints of sickness, and three placebo patients refused further
medication after respective complaints of rash, loss of appetite, and general ma-
laise.
DISCUSSION AND OVERVIEW
Narcotic antagonists have been used for several years in the treatment of addic-
tion, yet rarely has their use been put to controlled test. Originally, there seemed
to be a universally held assumption that except for side effects, which until the
introduction of naloxone had been the antagonists’ principal drawback, there was
little question as to their utility. More recently, this assumption has beenchallenged, both in clinical practice and in studies, such as the currently reported
one, designed to isolate their pharmacological contributions beyond the mere
palliative value of pill taking.
For a period of time, investigative efforts centered on the search for a “pure”
antagonist, i.e., one that would demonstrate little or no action of its own other
8/7/2019 Narcotic Antagonist Treatment of Addict Parolees by Dr. Charles Savage
than the theoretically crucial opiate blocking effect. Unfortunately, it is now be-
coming apparent that a pure antagonist may not necessarily be the best an-
tagonist; at least, results of controlled studies on contingently and dailyadministered antagonists 4*8.‘”tend to support the conclusion that with the less mo-
tivated patient, effectiveness as an antagonist often precludes satisfactory treat-
ment outcome. There is little reason to doubt that a pure antagonist successfully
blocks the euphoric and analgesic effects produced by opiates, theoretically reduc-
ing an individual’s incentive to use narcotics while medicated. Rather than inhibit-
ing the drug-taking behavior of the typical less motivated addict, however, the
principal effect of such an agent appears to be that of reinforcing avoidance of
medication and indulgence in otherwise uncooperative behavior.
In the present employment of contingent administration, one-half of the na-
loxone patients (27 of 55) either refused to continue to take medication or ab-sconded prior to the 6-month termination point. Although obviously contributory
in both instances, the relative extent to which this noncompliance was the result of
the narcotic antagonistic property of naloxone or of its contingent method of
administration could not be determined on the basis of available evidence. Besides
the narcotic blocking effect, other deterrent influences on continued treatment in-
volvement were undoubtedly operating in the situation. Naloxone, for example,
was not exactly pleasant to take, inasmuch as one out of every five patients com-
plained of gastrointestinal distress at one point or another during treatment. Also,
because of the relatively large dosage of naloxone required to achieve blockade,
the consumption of as many as four large, bitter pills by the addict parolee was attimes required. Considering these aversive circumstances, an increase in termina-
tion rate would not be unexpected. Should aversive and/or artifactual effects have
less bearing on the acceptance of the newer antagonist, naltrexone,” controlled
studies of this agent which are currently underway will hopefully offer more speci-
fic information on the relationship between blocking effect and retention in treat-
ment.
Another matter relating to retention in the present study bears consideration.
Though not statistically significant, seven of the parolees administered naloxone,
as opposed to only one administered placebo, were subsequently terminated from
treatment because of the commission of a new offense. (One of the naloxone caseswas incarcerated on the day he was first placed on medication.) Disquieting to
some extent because of its implication, this finding was not generally explainable
in terms of any discernible underlying pattern of reaction to naloxone.
In evaluating any addiction treatment program, retention in program, i.e.,
simply whether a patient remains in the program or not, is a misleading criterion
without consideration of the extent of narcotic drug use. Results illustrativeof this
were obtained from a recently concluded study* of the daily use of naloxone in a
“partial blockade” dosage as well as from the present study. Although as a group
the placebo patients in both of these controlled studies tended to remain in treat-
ment for longer periods of time than those administered naloxone, they were,nevertheless, deviating more in terms of narcotic drug use. Interestingly, the
possibility that contingent administration might in itself have therapeutic value
was also illustrated. Whereas, in the earlier study, one of every two patients
administered daily placebo produced positive urine specimens at least 40% of the
8/7/2019 Narcotic Antagonist Treatment of Addict Parolees by Dr. Charles Savage
time, only one of every four patients administered contingent placebo in the
present study deviated to this extent. Reflecting this difference in response to daily
and contingent administration, the average deviation rates for the respectiveplacebo samples were 28% vs. 11%. Although somewhat higher with daily
administration, narcotic positive rates for naloxone were less disparate under the
two conditions, uniformly ranging below the 40% level and averaging less than
10%.
Improved placebo effectiveness under contingent conditions was at least
partially responsible for the lack of any substantial naloxone-placebo differences
in the present study. Though statistically significant, the 4% differential in the 7%
vs. 11% narcotic positive rates for naloxone and placebo, respectively, was princi-
pally due to the deviations of only a few of the placebo cases. It might be argued
that for most patients, i.e., at least three out of four, the contingent administrationof placebo was associated with relatively cooperative behavior (attending the clinic
and providing a specimen at least 80% of the time) and positive outcome. Also,
these patients tended to remain relatively longer in treatment over the 6 month
period, and of course, experienced little or no “side effects.” Understandably, it
would be difficult to convincingly demonstrate the worth of any pharmacologically
active agent under such circumstances.
As mentioned, 33 parolees, or slightly more than 20% of the original 154 refer-
rals, did not demonstrate sufficiently deviant behavior during the 6-month ab-
stinence program to require the prescription of medication. These individuals
were identifiable as a group prior to program participation. Though configurally
similar, their mean MMPI profile was found to be significantly lower than that for
the remaining referrals on nine of the ten clinical scales examined. As further in-
dication of the relative stability of this subgroup, their mean community adjust-
ment rating at the 6-month evaluation point was 8.7, revealing good to excellent
global adjustment.
As also noted, another subgroup of initial referrals not included in the con-
trolled study was comprised of 24 parolees who either absconded prior to the the
reception of medication or refused to take medication during their participation in
the abstinence program in spite of evidences of deviation. These parolees were
indistinguishable in terms of pretreatment descriptive measures from those ac-
cepting medication who were thereby included in the study. On posttreatment
assessment, however, the relatively unfavorable status of 12 parolees refusing
medication who were available for evaluation at six months was revealed in a
mean community adjustment rating of 4.2 indicative of poor overall adjustment,
including fairly consistent narcotic drug use.
Except for preliminary findings by Resnick and his coworkers’2 that bear rep-
lication, efforts at the prediction of treatment response in the area of drug addic-
tion have been notoriously unrewarding. Meaningful analyses of the differences
between responders and nonresponders in the present instance were precluded by
the small number of successfully concluded cases.
The findings of the present study relating to the effectiveness of placebo again
highlight the importance of controlled research in the evaluation of any new treat-
ment procedure. Prior to this controlled examination of the contingent use of na-
loxone in an ongoing abstinence program, results of pilot research conducted at
8/7/2019 Narcotic Antagonist Treatment of Addict Parolees by Dr. Charles Savage
the clinic had been especially encouraging. In this initial work, criteria of effective-
ness, including clinic attendance, the extent of narcotic drug use, and final disposi-
tion at six months, were viewed in relation to already established baseline resultswith a sample of patients processed through the same clinic over a five year period
before the introduction of antagonist treatment. Comparative findings indicated
longer program involvement, less narcotic drug use, and less reinstitutionalization
with contingently administered naloxone. In view of presently reported results,
however, it appears likely that placebo reactivity was to a large extent responsible
for these initial favorable impressions.
With some individuals in the present study, there did appear to be reinforce-
ment value in the taking of antagonist medication. Although the evidence was not
overwhelming, the capacity of naloxone to attenuate the narcotic drug intake of
those addict parolees remaining in the abstinence program was at least demon-strable. It was principally in terms of treatment acceptance and dispositional data
that naloxone, in the dosages and contingent schedules employed, failed to demon-
strate its expected potential. Considering the generally low level of motivation in
the population in question, however, there is reason to doubt the utility of any
presently known narcotic antagonist administered under similar conditions.
Present results, therefore, do not discount the potential usefulness of naloxone in
other settings or under other conditions.
Granted an innumerable array of causative factors, compulsive narcotic use ap-
pears to be partially attributable to diffuse psychophysiological discomfort, the
alleviation of which is a significant reinforcer. The failure of chemotherapeutic in-tervention to deal directly with such discomfort will inevitably result in limited ap-
plicability and effectiveness. It is primarily for this reason that antagonists do not
seem to offer substantial rehabilitative promise for the typical parolee or street
addict. For many such individuals, there is simply no incentive or reward in the
taking of a chemical that denies them the relief they obtain from narcotics. Thus
viewed, antagonists can be expected to be no more effective in alleviating chronic
narcotics use than disulfiram (Antabuse) has been in alleviating chronic alcohol
use.
Considering the above, it seems advisable to supplement the search for pure and
longer-acting narcotic antagonists by further concentration on the development ofantagonists with non- or minimally addicting agonistic properties that are more
acceptable from the side effect standpoint than those that are presently available.
Judiciously used during the early stages of treatment, such agents would be more
likely to sustain the participation of less motivated addicts in therapeutic environ-
ments to which they might not otherwise be attracted.
SUMMARY
The results of a controlled study of the contingent administration of naloxone to
newly released addict parolees were viewed in relation to the goals of the narcotic
antagonist approach to the treatment of addiction. Program participation and nar-cotic usage data on 97 addict parolees, 55 of whom were assigned to naloxone and
42 to placebo, revealed that although demonstrating a capacity to attenuate nar-
cotic drug intake, the use of naloxone in contingent dosages ranging from 500 to
2000 mg was associated with a relatively high dropout rate during a prescribed 6-
8/7/2019 Narcotic Antagonist Treatment of Addict Parolees by Dr. Charles Savage