TREATMENT CHOICES IN OPIOID ADDICTION
Mahjabeen Islam MD FAAFP FASAM
More than 50,000 people die of opioid overdoses every year and now
more people are killed by opioids than traffic accidents or guns.
All of us know someone with the disease of opioid addiction and
everyday we either personally deal with the devastation that opioids cause, or
read or hear about it. Opioids are taking lives the way that the AIDS epidemic
did when it was at its peak in the 1980s and early 1990s. We were able to
control the AIDS epidemic and if the government, the health care system, law
enforcement and actually each and every one of us decides that we are going to
defeat this epidemic, we will.
First things
first: it’s a chronic disease
A lot of people think that
opioid addiction is a weakness, a personal failure or a character flaw. Society
and people like to feel stronger by making others feel weak. But we know from
medical research that opioid use disorder is a chronic disease, much like
diabetes, high blood pressure and asthma. And like these diseases it has no
cure, the same relapse rates, and, if you want to follow it, excellent and
successful treatment.
If you take diabetes as an example you know that some people have
a “touch of sugar” and others are insulin dependent diabetics. In mild
diabetes, some patients only need to watch their diet and exercise regularly,
others take pills to lower their blood sugar, and some have to inject high
doses of insulin every day.
So everyone who is prescribed or tries an opioid doesn’t get
addicted. We have receptors in our brains called mu receptors, which opioids
latch onto and we experience an opioid high. Everyone’s brain is different and
many factors like our genes, the age at which drugs are tried, the dose used,
the potency of the drug, whether it is eaten or injected, our social and family
condition, our psychiatric issues all control the mu receptor and whether we
don’t get a high, get a bit of a high or a very intense one.
Before determining the right treatment for opioid use disorder it
is vital to understand that this is a chronic disease. If you don’t understand
and accept this, treatment is probably not going to work for you.
There ain’t
no motivation pill
For any treatment to be successful the patient has to be
motivated. Families, courts, jobs or a society pushing a person to get sober
doesn’t work. The motivation has to come from within the person. I like to tell
patients that I don’t have the motivation pill, and if I did, my face would be
on the cover of Time magazine!
Patients who have been through treatment multiple times know that
that the times it worked, they had been motivated themselves. The times it
didn’t they were either half-hearted or had been pushed by other people or
factors.
As physicians we try to give the best treatment we can for the
patient, but we are not always able to judge the strength of a patients
motivation and dedication toward recovery.
It is very easy to see through the patient who is half hearted and
trying to dupe the system. Because of the large number of people that need
treatment, we have no patience, or room, for people that are either not ready
for recovery, or are trying to use the system, or both. We want to save the
life of someone who really wants sobriety, not play games with patients.
Counseling
is essential/Customizing treatment to each patient
With every kind of treatment, patients are more successful with
sobriety when they go through group and individual counseling. These sessions
help the patient understand what started their addiction, what their relapse
triggers are, what to do in case of a crisis, the importance of sober support
and getting back to school or work.
How often a patient should get counseling has not been scientifically
established; all we know is that counseling helps a lot with recovery. We
assess each patient and try to determine how severe their addiction is, as well
as their family and social situation, and come up with an individualized
service plan to best help the patient.
Some patients do well with once a week group therapy, while others
have to start with three to five times a week counseling sessions. Yet others
need to be in an inpatient facility or in residential treatment. It is
important to customize or tailor the treatment to each patient instead of
adopting a one-size-fits-all approach.
Treatment
choices
1.
Abstinence-based treatment
2.
Methadone maintenance
3.
Buprenorphine-naloxone: Suboxone,
Zubsolv, Bunavail
4.
Naltrexone pill
5.
Naltrexone injection: Vivitrol
Abstinence-based
treatment: you’re kinda on your own
The phrase “cold-turkey” comes from opioid withdrawal because when
opioids are stopped suddenly the person feels cold, has goose bumps, sweating,
nausea, vomiting, diarrhea, insomnia, anxiety, irritability and muscle and bone
pain. While the patient may feel that they are going to die; opioid withdrawal
does not kill and usually after two to five days, the severe withdrawal
symptoms go away and the patient may just be left with some cravings.
In the old days, all we could do was help patients through the
withdrawal with medications like Zofran for nausea/vomiting, Imodium for
diarrhea, Motrin for pain, Flexeril for muscle pain and clonidine for cravings.
And we counseled patients and hoped for the best. This form of treatment
doesn’t work well for all patients, in fact only a minority maintains sobriety
with this and relapse rates are high.
It remains a choice for those patients who don’t want any
medication-assisted treatment and there are patients that maintain long-term
sobriety with this and counseling.
Methadone
maintenance: the original treatment
Methadone is a long-acting opioid and in the 1970s methadone
clinics started in cities across the United States. The government tightly
regulates methadone clinics because methadone is a very powerful, long acting
and dangerous opioid and can kill easily. In a methadone clinic a physician
evaluates the patient, and calculates their methadone dose, mainly based on
their opioid use. The patient drinks
liquid methadone in the presence of a nurse and has to come every day to take
the liquid methadone.
Advantages of methadone maintenance:
1.
Potent opioid; takes away all
opioid withdrawal symptoms and cravings.
2.
Proven to reduce opioid overdose
death rates.
3.
Very close monitoring of patient,
so is good for complicated patients who have used high dose opioids for a long
time with little sobriety.
Disadvantages of methadone
maintenance:
1.
Daily visits to clinic.
2.
Difficult to hold down a job or
go to school.
3.
Unfortunately very high methadone
doses are typically used. Some patients are therefore high on methadone.
4.
Difficult to wean off as
withdrawal from methadone is particularly severe.
Buprenorphine-naloxone:
Suboxone, Zubsolv, Bunavail
(For ease of understanding I will be using Suboxone to represent
buprenorphine-naloxone)
Active ingredient is buprenorphine and not naloxone:
A lot of people think that Suboxone works because it has the
opioid blocker, naloxone, in it. This is not true. Suboxone, Zubsolv and
Bunavail’s active ingredient is buprenorphine, which is an opioid.
Buprenorphine is not a powerful opioid and has just enough of an effect on the
mu receptor to treat withdrawal symptoms and take the craving for opioids away.
When Suboxone is used under the tongue, the buprenorphine is
absorbed and becomes active. The naloxone does not work when it is taken under
the tongue. Naloxone only becomes active when it is injected and if Suboxone is
liquefied and injected the naloxone in the Suboxone places a patient in
immediate and severe withdrawal. So the
reason that naloxone is placed in Suboxone is to prevent patients from
liquefying Suboxone and injecting it.
A great medication:
Buprenorphine-naloxone is a great medication and has been
successful in turning millions of lives around. Eight to sixteen milligrams per
day is a common dose. The lowest dose should be used which keeps the patient’s
withdrawal symptoms away, especially the cravings. At sixteen milligrams the mu
receptors are saturated and when a higher dose is given it is only the bad side
effects that the patient notices, not necessarily an improvement in cravings or
withdrawal symptoms.
Stages of treatment:
1. Induction
2. Stabilization
3. Maintenance
4. Weaning
Induction: This is the first stage. The patient is requested to present in
opioid withdrawal so the Suboxone can be started immediately. The lowest
possible dose of Suboxone that will take care of withdrawal is given to the
patient and they are rechecked in two to three days. If the urine drug screen
in the next visit is negative, and a dose increase is requested, we do raise
the dose.
Stabilization: in the next few visits we focus on stabilizing the Suboxone
dose. Sometimes the dose is too much and the patient feels that they are
nodding during the day, and thus the dose is reduced. Others feel that the dose
is insufficient. If the urine drug screen is negative and the patient is
compliant with counseling, the Suboxone dose is increased.
Maintenance:
This is the phase when the patient is comfortable with their dose
and typically is the longest of all the phases of buprenorphine treatment.
Weaning:
Depending on the dose of Suboxone that the patient is on, it can
take one to four months for a patient to be weaned off Suboxone completely. The
dose of Suboxone is lowered very gradually and the patient advised that they
will feel opioid withdrawal symptoms for two to five days, and after that, they
are pretty much fine. Essentially all patients realize that they had been
unnecessarily nervous about dose reduction, and indeed they felt a little achy
and have a bit of insomnia for a couple days, but that after that they were
fine.
Duration of treatment:
This is different for different people and we try to customize the
treatment to each patient. Some patients are on Suboxone for a few months, some
for a few years and others indefinitely. Just like they had with their choice
of opioid, patients get very attached to Suboxone and some become very
resistant to dose reduction. Patients want to reduce their doses by one-quarter
films and I reassure them that, just the way they had gotten attached to their
drug, they have now latched on to Suboxone and we reduce the dose by half a
film, or four milligrams, every two to four weeks (when the patient is on eight
to sixteen milligrams of Suboxone).
Side effects:
Suboxone can cause drowsiness, constipation, weight gain and leg
swelling. And of course dependence as it is an opioid.
How long Suboxone?
Research does not guide us regarding the duration of treatment
with Suboxone. To best treat patients I have divided patients into three
categories with regard to duration of Suboxone use:
1.
Short term treatment
2.
Medium term treatment
3.
Long-term or indefinite treatment
Short-term treatment:
The patient is on Suboxone for a few weeks and is rapidly weaned
to zero and placed on naltrexone.
Medium-term treatment:
This treatment is for one to two years and ideally
I prefer the dose of Suboxone to be eight milligrams or below.
Long-term or indefinite treatment:
I reserve this for patients who have
concurrent psychiatric illnesses, such as not well- controlled bipolar disease
or schizophrenia. If treatment is going to be indefinite, I prefer the dose to
be eight milligrams or less.
We try to use the lowest Suboxone dose
possible, as patients themselves realize they do not need more than eight
milligrams and some then decide to sell or share it.
“Switched one addiction with
another”
People unfamiliar with current research,
those stuck in the abstinence-based model and fans of the 12-step program,
claim that treatment with Suboxone is switching heroin for Suboxone, an illegal
drug with a legal one. This is entirely untrue. And a typical attempt to make
oneself look good and the opioid addicted patient feel bad. We have research
that shows that Suboxone has a healing effect on the brain and is an excellent
bridge from opioid addiction to a life of sobriety.
Naltrexone pill and injection (Vivitrol)
Naltrexone is a long-acting opioid antagonist
and it was initially FDA approved in 2006 for the treatment of alcohol use
disorder. In 2010 it was approved for opioid use disorder. Unlike Suboxone,
naltrexone does not have an opioid in it and can be prescribed by any
physician. To prescribe Suboxone a physician has to be specially trained in
prescribing it.
Suboxone and methadone have a lot of research
data proving their great outcomes in maintaining sobriety, and reduction in
opioid overdoses. Studies show that naltrexone works well in patients who are
very committed toward their sobriety. In maintaining sobriety and preventing
opioid overdoses, Suboxone and methadone are far superior to naltrexone.
Some patients don’t want to be on an opioid
like Suboxone and this is understandable. But it is important to remember that
comparing Suboxone to the naltrexone pill or the shot, Vivitrol, is like
comparing apples to oranges.
Certain professions like pilots or truck
driving do not allow Suboxone and in that situation naltrexone is a good
choice.
Naltrexone cannot be given when an opioid is
present in the system, as it will immediately put the patient in severe
withdrawal. Naltrexone is started either at the start of addiction treatment or
after Suboxone has been weaned down to zero.
Naltreone pill:
The naltrexone pill is prescribed at 50mg
daily and is inexpensive and approved by essentially all insurance companies.
Naltrexone injection/Vivitrol:
Vivitrol is a monthly injection and lately
has been heavily promoted by its manufacturer Alkermes and its use is
skyrocketing across the United States. It costs about $1200 per injection and
380 milligrams is injected once a month intramuscularly. Several court systems
across the country are also concentrating on Vivitrol. It is important to
understand that both the naltrexone pill and the Vivitrol injection work, the
only difference being that the pill can be stopped by the patient but once the
Vivitrol is injected it obviously cannot be removed, and its effects last one
month. And even though use of an opioid while on Vivitrol will place the
patient in withdrawal, patients have been known to relapse while on Vivtrol.
The intense marketing of Vivitrol has led to
its indiscriminate prescribing by physicians and its recommendation by the
justice system and this is placing a terrible burden on our health care system.
Vivitrol
is not a cure-all and the naltrexone pill is just as good as the injection.
Side effects of naltrexone:
The main side effects of naltrexone, both
oral and injection, are fatigue, headache and nausea.
So what should you do?
I’ll list out some options of what you can do
when you enter a program:
Option 1:
·
If the patient has not used
opioids for at least three days and the urine drug screen is negative the naltrexone
pill can be started.
·
If opioids are present in the
urine, a return appointment can be made after three days and naltrexone can be
started then.
·
Naltrexone pill can be continued
indefinitely.
·
If taking the pill everyday is a
problem and the insurance company covers Vivitrol, it can be tried.
Option 2:
·
Start on Suboxone.
·
In return visits try to stay on
the lowest dose of Suboxone that takes care of opioid withdrawal and cravings.
·
After four to six months of
treatment, start weaning process to zero.
·
After Suboxone has not been taken
for one week and the urine drug screen is negative for it, naltrexone can be
started.
Option 3:
·
Start on Suboxone
·
Have regular discussions with
your doctor about the duration of treatment and if it is mutually decided that
you need to stay on Suboxone indefinitely, make sure you are on the lowest dose
that would control opioid cravings.
Option 4:
·
Go through opioid withdrawal and
go with abstinence-based therapy. Meaning no Suboxone and no naltrexone.
·
I am not in favor of this option
as the patient is unprotected in dealing with a disease and because oral
naltrexone is cheap and effective in the motivated patient.
The lives of millions of opioid addicted
patients have been transformed after their entry into programs that treat
opioid use disorder. And being the instrument of such a massive change in
people’s lives has been, by far, the most humbling and gratifying experience in
my life.
Dr. Islam is medical director of UMADAOP of Lucas County and is
board-certified in Addiction and Family Medicine. She has over twenty-five
years experience in Addiction Medicine and has worked in all phases of
treatment, from inpatient to intensive outpatient, residential and ambulatory
treatment.
This article was originally published in the UMADAOP magazine in October 2017
