Fear of methadone maintenance
Authors: Richard S. Winslow, Verner Stillner, David J. Coons, Mason W. Robison
Journal: American Journal of Psychiatry (1987)

idal side effect during the 7-day study period, with no differences in severity or time of onset between the high- and low-dose groups-hardly an argument against prophylaxis. Drs. McEvoy and Simpson surmise that the 20 chlorpromazine patients in the recent study in which Dr. Simpson participated (3) suffered no acute dystonic reactions because they were taking lower chlorpromazine-equivalent doses. In contrast, we believe that the result was due to chlorpromazinc itself, which, like other low-potency agents, causes a low incidence of acute dystonic reactions because it is quite anticholinergic in its own right. Dr. Simpson and his associates (3) themselves made this point nicely by citing a study by Snyder et al. (4). There are even studies-eg., that of Carter (5)-which suggest that higher doses of haloperidol may protect against early extrapyramidal side effects by exerting sufficient anticholinergic action. We conclude that the whole concept of using chlorpromazine equivalency is only valid when comparing antipsychotic potency and is invalid and misleading when assessing the relative likelihood of causing extrapyramidal side effects. In our own study we attempted to assess the advantages versus the disadvantages of prophylactic anticholinergics. We do not claim that prophylaxis will eliminate acute dystonic reactions entirely. We do not claim that anticholinergics are completely without problems, especially with respect to prolonged use. However, we strongly disagree with the statement that “psychotic patients do not usually speak eloquently about their subjective state.” Instead, we heartily agree with the words of Dr. Simpson and his associates (3): “Dystonic reactions are frequently frightening because of their abrupt and dramatic onset and can, on rare occasions, be life-threatening.” Our experience both during our prospective study and afterward has been that psychotic patients, when offered an adjunctive medication that they are told may decrease the likelihood of an acute dystonic reaction, eagerly accept it and its possible risks of added anticholinergic symptoms. The most eager patients are precisely those who have themselves experienced or witnessed acute dystonic reactions. Like Drs. McEvoy and Simpson, we generally support a policy of using the lowest effective neuroleptic doses for all patients. We might even consider a policy of using chlorpromazine itself, or other low-potency agents, for all patients for whom side effects such as significant sedation and frequent hypotension are not a barrier to adequate antipsychotic dosage. The fact remains, however, that high-potency neuroleptics have some advantages for many patients and that even in modest doses they appear to cause a substantial percentage of acute dystonic reactions. Until consistent evidence appears that low doses produce a clinically insignificant rate of these reactions, we will continue to recommend that the safest and most humane approach is a brief course of prophylactic antiparkinsonian medication when one is starting patients on high-potency neuroleptics.