AN EXPLANATION OF WHY MEDICATION-ASSISTED TREATMENT
(buprenorphine and naltrexone, but not methadone)
Can greatly help those desiring to recover from opioid addiction
We are in the throes of a nationwide heroin and opioid addiction epidemic. The consequences have been devastating. In our area, many lives have been lost and families destroyed. What can be done about this? What is the most successful way to recover from opioid addiction?
Multiple scientific studies have shown that for most opioid addicts, a comprehensive approach that includes addiction counseling, 12-step support groups, addressing of associated physical and mental health issues, AND medication-assisted treatment for some period of time offers the best long term recovery results. The data is clear. Those who are treated with buprenorphine (Suboxone and other brands) and/or naltrexone (Vivitrol and generic tablets) for some time, IN ADDITION to a comprehensive treatment program, have the greatest change for long term recovery. That does not mean that someone cannot recover from opioid addiction without the use of these medications. Many do fine without them. But OVERALL, those who receive such medications for some time do better than those do not.
Nevertheless, the use of Suboxone (especially) and Vivitrol remains highly controversial. Some ask, “Aren’t you just substituting one drug for another? One addiction for another?” That’s a fair and reasonable question, but this article explains why that is NOT the case, at least as regards Suboxone and Vivitrol (we do not recommend methadone, for reason explained later.) This article explains how the use of Suboxone or Vivitrol can be very helpful when they are PROPERLY prescribed, and as but one part of a truly COMPREHENSIVE addiction recovery program.
That’s the approach we take at North Dayton Addiction Recovery. We are a recovery– oriented program. We do NOT believe in prescribing these medications indefinitely, and we have certain requirements for our patients, including the professional addiction counseling, complete various self help strategies, particpate in support meetings and/or have a sponor, have associated mental and medical issues addressed, take medication as directed, and maintain sobriety from all addictive drugs as evidenced by frequent and random drug testing.
Back in the 1950’s, some scientists for the bright idea to put a electrodes in various parts of a rat brain and turn on the juice. They wanted to find out if there would be a place in the brain where the rat actually enjoyed the stimulation. If so, the rat could be trained to press a bar that continued the electrical charges.
They put the electrodes on the right side. Then on the left. Mr. Rat could care less. And here, and there, and so on, still no effect. Except, finally, they discovered one area, deep in the brain, just above the brainstem. When the juice was turned on there, the rat went crazy. They hit the bar, over and over and over to get more. They didn’t stop to eat, drink, to make love, to read the newspaper, they just kept hitting the bar until they dropped dead.
Following this, the scientists decided to dip certain chemicals down a pipette into that same area of the brain. Most chemicals has no effect whatsoever. The rat stayed quiet. But a few chemicals made them go crazy, just like the electricity had. Things like cocaine, and methamphetamine, and heroin.
Turns out we humans have the same area in our brains. It’s a part of the brain, deep in the center, that we share not only with rats and other mammals, but with salamanders, birds, and thousands of other species. It’s popularly known as the “pleasure circuit,” also the “survival circuit,” of the brain. Nature has given us this pathway to motivate us, to reward us, for doing things that enhance our survival, or the survival of our species. Things like eating sugar, which is rare in nature, or having sex, or so on.
Scientists have stimulated this part of the brain in humans, just like they’ve done with rats, and the results have been stunning. Subjects report that the sensation is “beyond ecstasy,” “better than orgasm,” and so on. In other words, this area of the brain is incredibly powerful and motivating.
Of course, we don’t see people walking around with electrodes sticking out of their heads. But many people take drugs that cause the same effect by stimulating their pleasure circuits chemically.
Less than a hundred of the 30 million or so chemical compounds we know of are able to powerfully stimulate our pleasure circuits, creating what scientists call “reward.” And unless a chemical is able to produce the reward, it will not be addictive. Therefore, we have no epidemic of addiction to broccoli.
We do have an epidemic, however, of addiction to drugs such as heroin, also cocaine, methamphetamine, and others, because all of them powerfully stimulate the pleasure circuits in our brain.
Okay, but what does that have to do with medication-assisted-treatment for opioid addiction? Well, we need to know one more thing about the addicted brain. Fairly quickly after a person begins abusing addictive drugs, and especially in the case if heroin and opioid pain pills, the brain makes adjustments. It recognizes the dangers, and it makes itself less sensitive. The brain turns many of it opioid receptors from outside the cells, it changes its proteins and even its DNA, all to lessen the drug’s effects. The result is what we call “tolerance.” That is, the drug user has to use more and more drug to get the same effect as before. Someone who began taking one or two opioid pain pills a day gets up to 20 pills a day. Someone who started on ¼ gram of heroin a day gets up to 2 grams a day.
The really, really crucial thing to understand is this: These changes in the brain takes a lot of time to be reversed. When a longstanding heroin addict stops using heroin, even after the immediate withdrawal period, his or her brain is not back to normal. It’s not even CLOSE to being back to normal! In fact, it apparently takes at least six months for that brain to return to reasonably normal, based on a number of studies, including sophisticated brain scans. During the early weeks and months, the brain is seriously out of whack, and it pours out stress hormones such as ACTH and cortisol for quite some time. The result is cravings that can persist for many weeks after stopping the drug. (Interested to learn more about this “Broken Brain Syndrome?” Ask for our our blog specifically addressing this!)
Consider further the social and life situations that many heroin addicts find themselves in when they desire to quit heroin and get help. Many live in bad situations, perhaps with another active drug user or two in the household. They may have no friends who are not active drug users. They have little understanding of what it would take to become drug free. They’re not hooked up with addiction recovery counseling, which can take weeks to set up. They may have associated mental diseases that need to be addressed.
Consider further the social and life situations that many heroin addicts find themselves in when they desire to quit heroin and get help. Many live in bad situations, perhaps with another active drug users or two in the household. They may have no friends who are not active drug users. They have little understanding of what it would take to become drug free. They’re not hooked up with addiction recovery counseling, which can take weeks to set up. They may have associated mental diseases that need to be addressed.
The likelihood of remaining drug free in such circumstances is low. That’s because, early on, physical cravings are strong and the addicts has insufficient resources and support to resist them.
How, then, do medications such as Suboxone help a heroin addict early in recovery? In a nutshell, they take away drug cravings during the critical early weeks and months in which the addicts starts to engage in a recovery program. They buy time.
It’s hard enough to face the truth about the consequences of one’s addictions, to come clean, to learn new ways of thinking, to learn how to deal with stress and painful feelings, to sometimes find a different place to live or escape bad friends and gain good ones, to engage in counseling groups and 12-step groups, to get a sponsor, to have mental and physical health issues addressed, and so forth. It’s hard enough to do all that and deal with intense cravings at the same time!
Suboxone, and to a lesser extent Vivitrol, takes away the cravings, making it far easier for the opioid addicts to focus on recovery. Then, once recovery has taken hold, the medication can be slowly tapered and stopped. (The taper is gradual enough to avoid triggering brain stress and craving.) In a way, the medication is a lifeboat, keeping the addict from drowning until they are able to swim on their own.
How, then, does medication-assisted treatment, say with Suboxone, work exactly?
First of all, the medication provides what the brain is craving, but in a much safer way. In the case of cigarette addiction, nicotine patches provide what the brain is craving, namely nicotine, but without the thousand or so cancer-causing and lung-damaging chemicals in cigarette smoke. In the case of heroin addiction, Suboxone provides an opioid, buprenorphine that’s vastly safer than heroin, and free from deadly contaminants.
Second, the buprenorphine in Suboxone does not fully stimulate the opioid receptors in the brain like heroin does. Therefore, people do not get high from Suboxone, it just blocks their cravings. Yes some addicts, it’s true, being addicts, have found ways to get a little bit of a high with Suboxone, but the medication is designed to make that difficult, and in my experience patients in a good recovery program rarely misuse it.
So yes, we are substituting one drug for another, but we’re substituting a drug that is vastly safer, that blocks cravings during the most vulnerable time for relapse, and that enables the addict to focus on recovery. And we’re using that medication for only a limited period of time, until the addict is established in their recovery – after which we taper them off.
In our program, we keep our opioid addict patients on a higher dose during the beginning of their recovery, by which time a good recovery program is usually established. We then slowly taper the dose until they are completely off. Because the taper is gradual, the brain is able to make the adjustments back to a normal state without precipitating cravings. For those who stick with our program, the success rate is high. Most of our patients are completely off Suboxone by 18 months following the start of our treatment.
Our approach, however, is not followed by everyone. Some prescribe Suboxone or other medications at a full dose for an indefinite period, years and years on end, without requiring the patient to work a recovery program.
We do not agree with that approach, and even though many people are happy to take medication alone forever, I don’t think doctors who give these people what they want are serving them very well. That’s because taking medication forever simply isn’t necessary, in our opinion. And if you don’t deal with the disease of addiction, the patient sooner or later is going to relapse on heroin or take other drugs.
Now, what about methadone? Like buprenorphine, methadone is also an opioid drug replacement. It also blocks cravings. However, by federal law, methadone can only be dispensed for the treatment of opioid addictions through centers specifically approved by the government for that purpose. We are not such a center, nor do we desire to be.
That’s because we believe buprenorphine is a better medication. Unlike buprenorphine, patients develop tolerance to methadone. That means their dosage level has to be increased beyond their starting amount, often to high levels. And at those levels, serious side effects can occur. The higher dose of methadone one takes, the harder it is to taper off. Another problem with methadone is that when it ends up on the street, which it often does, it causes a significant number of overdose deaths, given that it accumulates in the body far more than people realize.
Methadone does have the advantage of being cheaper than Suboxone, though when you assess the cost of having to visit a clinic every day, that’s less so. Methadone also is not limited by any quota on the number of patients who can receive it.
What about Vivitrol? What is that, exactly? And how does it work? Vivitrol is long-acting, injectable form of naltrexone. It’s given as an injection in the buttock, once every four weeks. Unlike buprenorphine or methadone, the naltrexone in Vivitrol is not an opioid. In fact, it’s an opioid antagonist. So why does it help heroin addicts recover?
The reason is that naltrexone also occupies the opioid receptors in the brain, thereby reducing cravings. Vivitrol does reduces cravings as well as buprenorphine does, however, the patient has to be off all opioids for at least 7 days before it can given. That’s why Vivitrol is often not good treatment for heroin addicts in the very early part of their recovery, especially if they’ve been taking a large amount of heroin recently. If an inpatient detox isn’t available, or detoxing long enough at home isn’t an option, then usually it’s better to start those patients on Suboxone, get them stabilized, tapered down and off the Suboxone, and then get them on Vivitrol.
However, Vivitrol is a good option for addicts who have been off their opioids for a while, such as someone being released from incarceration. Also, since it’s given as an injection that lasts for four weeks, it’s a good choice for those who can’t be trusted to take Suboxone as directed. Once the Vivitrol is given, it’s going to be there for four weeks. During that time it not only will reduce cravings, it also will prevent any high from using heroin, they would get no effect from it.
Let’s consider now the brands and expenses of buprenorphine and Vivitrol.
Buprenorphine/naloxone comes in a variety of brands; Suboxone is the most common and comes in the form of strips or tablets that places under the tongue until they dissolve and are absorbed directly into the bloodstream. Suboxone contains buprenorphine, which is the active ingredient. It also contains naloxone, which helps blocks any high the user might get by abusing it.
Suboxone costs about $9 per strip after use of a discount card. For someone on the full does of two strips per day, that amount to about $500 a month. Zubsolv and Bunavail cost about the same. The generic tablets can be found for as little as $4/each. Fortunately, almost all insurance companies cover at least one of the brands.
Vivitrol is considerable more expensive than Suboxone. The retail price is around $1000 an injection. Fortunately, most insurance companies, including Medicaid, cover Vivitrol. For patients without insurance, however, it’s usually not an affordable option. In such cases, we can consider the use of naltrexone tablets. You can get the same effect as Vivitrol by taking a naltrexone tablet every day. The problem, however, it that you could choose on any given day not to take your tablet, and if you miss your dose then find yourself in a compromising situation, you could find yourself in a bit of trouble.
Is medication-assisted-treatment necessary for EVERY person who wishes to recover from heroin or other opioid addiction? OF COURSE NOT. Many heroin and pain pill addicts are able to recover without the use of any medication whatsoever, and we’re delighted they’re able to do so!
But studies overwhelmingly show that IN GENERAL, the success rate for lasting recovery from opioid addiction is highest when there is a COMBINATION of medication, at least for a time, and a comprehensive recovery program.
This article was written by Steven E. Stoller, Medical Director at Better Life Wellness Center in Richmond, IN. Dr Stoller is board-certified in Addiction Medicine and has served as a mentor to our practice since 2018 when we resumed his private practice upon his retirement.