Episode 25
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What treatment options are there for opiate addiction?
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What is medication assisted treatment?
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What’s the difference between agonist, partial-agonist and antagonist options?
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What is the therapist role in treating opiate addiction?
The opiate epidemic is all around us. We hear about the deaths and the dangers. Most of us know a bit about it, but we may not know enough details to help our addicted clients. This is the last part of a mini-series about opiates and heroin. The goal is to help you get a clear picture of this issue, how it impacts people and what treatment looks like.
Helpful Links
Opioid vs. Opiate: What’s the Difference?
Opioids: Listed From Strongest to Weakest – PAX Memphis
Understanding the Epidemic | Drug Overdose | CDC Injury Center
Prescription Opioids | Drug Overdose | CDC Injury Center
Opioid Overdose Crisis | National Institute on Drug Abuse (NIDA)
Overdose Death Rates | National Institute on Drug Abuse (NIDA)
Effective Medical Treatment of Opiate Addiction | Substance Use and Addiction | JAMA | JAMA Network
Methadone maintenance treatment (MMT): a review of historical and clinical issues – PubMed
Methadone Therapy for Opioid Dependence – American Family Physician
What Is Methadone? | Psychiatric Research Institute (PRI)
What Is Naltrexone? | Psychiatric Research Institute (PRI)
What Is Vivitrol? | Psychiatric Research Institute (PRI)
Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion
The history of the development of buprenorphine as an addiction therapeutic – PubMed
Suboxone: Rationale, Science, Misconceptions
Buprenorphine – an overview | ScienceDirect Topics
Overview | National Institute on Drug Abuse (NIDA)
Fentanyl depression of respiration: Comparison with heroin and morphine
Maintenance Medication for Opiate Addiction: The Foundation of Recovery
Current status of opioid addiction treatment and related preclinical research | Science Advances
Prevent Opioid Abuse and Addiction | HHS.gov
Psychologists’ role in helping to treat opioid-use disorders and prevent overdoses
Tramadol for the Management of Opioid Withdrawal: A Systematic Review of Randomized Clinical Trials
Opioid Overdose Prevention Programs Providing Naloxone to Laypersons — United States, 2014
Cannabinoid and opioid interactions: implications for opiate dependence and withdrawal
Safety And Efficacy Of The Unique Opioid Buprenorphine For The Treatment Of Chronic Pain
Opioid Overdose Reversal with Naloxone (Narcan, Evzio) | National Institute on Drug Abuse (NIDA)
What are misconceptions about maintenance treatment? | National Institute on Drug Abuse (NIDA)
Opioid Agonists, Partial Agonists, Antagonists: Oh My!
Free Treatment Tool https://betsybyler.com/treatment-tool/
Transcript
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance Podcast. This is Episode 25.Today, we’re going to be wrapping up our conversation about heroin and opiates.
I’m certain that at some point in the future, we’ll revisit these things because heroin and opiates are definitely something that are here to stay. The point of this series was to give you the basic information about the opiate epidemic. As well as treatment options.
In the first part of this series, we talked about the fact that heroin was synthesized as a derivative of morphine in the late 1800’s. It was supposed to be non-addictive and was being used to treat opium addiction.
Sales of legal heroin stopped around 1924 with the passage of the Heroin Act. The act restricted sales of heroin, other opioid driven medications were still available for doctors to prescribe. During that same time period, oxycodone was discovered. The hope was that this would be the answer to having analgesic effects, but not an addictive potential.
In the early 1980s, the medical community had a strong fear of prescribing opiates. President Reagan had encouraged American people to not tolerate drug use anywhere, anytime by any person. What changed the landscape was the increasing need to manage chronic pain and pain post-surgical interventions.
In the nineties, opioid medications were reproduced with time releasing effects. This was thought to be safer. Between the years 1997 and 2002 morphine prescriptions increased by 73%, hydromorphone increased by 96%, fentanyl prescriptions by 226%, and oxycodone by 402%. By 2015, we have a national overdose record of 52,000 plus deaths. I believe that number is probably higher than that.
In the 1960s and 70’s methadone came into the public light in the United States. Methadone is in the opioid family. It’s what’s called a synthetic opioid meaning that it’s made in a lab. Methadone was developed first in Germany during and after the second world war to manage pain.
There was a time when methadone was the only treatment for opioid addiction and used for people who were addicted to other types of opioids. From about the 1960s to the 1990s, it was very difficult to get on methadone treatment. Because of some things that happened during world war one and after, the American Medical Association had opposed ambulatory clinics for methadone treatment. .
Between 1970 and 1990, the methadone regulations would change a couple of different times; each time trying to make it more available for people who needed it for treatment. Opiate addicts were being depicted in a very negative light. Methadone was not something that was really popular in terms of treatment.
The rest of the history about methadone is incredibly involved and complex. I’m putting links in the show notes to a couple of articles for those of you who are interested. For our purposes though, methadone is the first of the maintenance medications that we’re going to talk about today.
Medication Assisted Treatment: Methadone
So let’s talk about that word, maintenance. Maintenance medications, refer to things that treat opioid dependence, such as methadone or buprenorphine. These medications are opioids and people who are not dependent on them absolutely can get a high or a euphoria from them. Because of this there’s some controversy over whether this is appropriate or if it’s just substituting one drug for another .
There were some treatment programs that took the word abstinence to mean that these medications were not allowed. So when they said they were “abstinence only”, they meant that you couldn’t be taking any of these maintenance medications. I believe that there are probably some facilities that still operate this way.
Sometimes it’s due to the fact that they don’t have medical staff on board and can’t be dispensing these kinds of medications. Others probably exist because of philosophical differences. In the episode about harm reduction and abstinence, I make the case that we need both harm reduction and abstinence-based approaches. I believe that someone who is on maintenance medication is sober and are abstinent, as long as they’re taking it as prescribed.
Maintenance medications are designed to be taken once per day. In some cases twice, but typically down to once per day and the person goes on with their life as usual. Taking care of kids, families, jobs, engaging in life, those sorts of things. The research is really solid that people are able to do these things and that they aren’t engaging in criminal activities.
Certainly there are going to be exceptions, but the evidence is really compelling that these things work. So I want to be really clear that I believe that this “counts as sobriety” and is abstinence.
The idea behind these maintenance medications is that a person could if need be, stay on them permanently. This is another reason that people have issue with it. They want this to be a limited time thing. I agree it would be nice to not have to have them take medications forever. If that person is unable to stay sober off of them, then this is a better alternative in my opinion.
These medications are extremely powerful as they are built to treat heroin addiction.. Getting off of these medications requires an incredibly slow taper period. If you’re going to taper down this medication, even a small drop in dosage is going to cause withdrawal.
Methadone remains the medication that has the most stringent level of regulations around it. In order to prescribe methadone, you have to be what’s called an OTP or an Opioid Treatment Program. That is a special designation with a lot of specific rules and regulations around it. Average doctors, or even average treatment centers or clinics, aren’t able to do this and it’s a complicated process to become an OTP.
The goals of using this type of medication are to prevent withdrawal, reduce cravings, and block the euphoric effect of illicit opioid use.
Finding the right dosage, moving from heroin to methadone can be tricky. As we talked about in our last episode, you’re never quite sure how much we’re talking about how “pure” the heroin is. There’s a little bit of trial and error here to find a place where the person is at maintenance level and not in withdrawal and not nodding out. A lot of the literature suggests that somewhere between 80 to 120 milligrams is appropriate. This is a daily dose taken in liquid form, typically at a clinic.
So the way methadone clinics work is that you would be on the list, you would get inducted and each day you would show up for your dose. . You take the dose, which is usually a red liquid, in the presence of the counselor or the person who’s administering it. And then you leave and come back the next day. Sometimes people are given “take-homes”, meaning that they can take their dose home for the weekend, allowing clinics to not have to be open seven days a week. Common side effects of methadone are restlessness, nausea or vomiting, slow breathing, itchy skin, heavy sweating, constipation, and some sexual side effects.
One thing of note for methadone is that it has been the treatment of choice for pregnant women who are going through opioid withdrawal or trying to quit using. Opioid withdrawal, as you can imagine, is very difficult on a developing fetus and we don’t want to encourage continued opioid or heroin abuse while someone is pregnant. Methadone is found to be safe to use with pregnant women.
Methadone is considered a full agonist, meaning that it fully binds to the opiate receptor. Other opioids are also full agonists. The person will be physically dependent on methadone. We don’t have any medications in this maintenance class that don’t continue the opioid dependence.
What it does is bring someone off heroin and give them a steady dose of methadone that isn’t going to increase cravings and that they can typically stay with for quite a while without needing to increase. Yes, of course, there’s going to be dependence to this, but it’s a much slower process.
So here’s the issue, this is a lot of opinion based on my experience with methadone clinics and so I want to throw that out there. Methadone can be an effective treatment. If we didn’t have any other options, I would support it a hundred percent. We do have other options though, that I think have less risk and can be done in a different setting and in a better way.
I’m certain that somewhere in the country, somebody is doing methadone treatment in a good, ethical and appropriate way. My experience with methadone clinics, however, has not been that. The methadone clinics that I’ve had experience with are for profit organizations. They run patients through at high volume and the people pay cash for the most part. So we’re talking thousands of people who desperately have to have this medication every single day or else they go into immediate withdrawal who pay cash for these medications.
I wonder then what the motivation is for the owners to decrease the amount of medication and to encourage people to taper down on methadone. If you have a bunch of people who have to have 80 to 120 milligrams a day, and if they start trying to taper, then they’re eventually going to not be customers and they’re also not going to need as much medication. I don’t understand how you can do methadone treatment for drug addicts in a for-profit environment and not have corruption. I just don’t see it.
I’ve always worked for non-profit organizations and even in nonprofits, budget is king. We have to make ends meet. We have to deal with productivity and that pressure is always there. I felt that as a middle manager and as a director. For those of you who are working in agencies, you know, that productivity is a real thing. I often see people online asking how much is full time. Some people are suggesting that 36 clients a week is full-time. Some people are saying it’s 25. that tension exists between line staff, therapists and management.
In a methadone treatment center we’re not talking about them going for counseling. We’re not talking about them having treatment in terms of learning about addiction, why they were using, going to therapy. For the majority of the places I’m familiar with you go in, they ask you different questions about the week. You might have a drug test depending on the place, but that’s not necessarily mandated and I’m certain that regulations vary by state. But typically it’s a short visit, especially if you have to go every day. There’s no requirement for anyone to do any kind of other treatment than that medication. I see this being really lucrative for the person who owns it because short visits and you’re running as many people as you can do per day. That’s a lot of money.
Because of the regulations on methadone, they’re often separate from a regular treatment center because you have to have that special designation. Methadone can be an option in my opinion, for people who are on really high doses of heroin and dropping to the other maintenance medication would be an incredible withdrawal.
So in addition to the for profit nature of the business, not having any kind of psycho-educational treatment or therapy that’s part of the program. I don’t love people having to go every day and stand in line with other addicts. People who are going there are going to be in varying stages of change. They may be going there and also using other substances. They may be going there because they have to, and they’re not really committed to recovery
Every addict is in a very different place that is very unique to them. If all of those people aren’t committed to a specific lifestyle they can easily influence each other. It’s super normal for us as addicts to bring others along with us when we’re going to go do something we shouldn’t. That’s just part of the nature of using. Many people do end up using alone, but it’s not nearly as fun.
So the idea that someone who’s in recovery is going to stand in line with other people in varying stages of change is not my favorite. I remember I was getting a tattoo a few years ago and ended up talking with my tattoo artist. He mentioned that he is in methadone maintenance.
We were talking about how difficult it is for him to get there every day. Sometimes it could take up to three hours just waiting in line to get to his turn because there’s a lot of people to get through. He pays cash for this. There are randomized drug tests. So sometimes he has to take one and then it takes longer or not just sort of depends. A little like going to the airport and you might get picked for a scan.
So I was talking with him about the other options. Because he’d been on methadone maintenance for three years and was doing pretty well in his life and in staying sober. He was really interested in the idea of trying something different that wouldn’t require him to be there daily, and wouldn’t require him to shell out cash.
Medication Assisted Treatment: Suboxone
One of the medications I’m referring to is buprenorphine. There are two forms of buprenorphine. One is called Subutex. That was the first one that was created. The second is Suboxone. This is a partial opiate agonist. Partial agonists cause less confirmational change and receptor activation. As the dose of a partial agonist increases the analgesic activity plateaus.
Subutex and Suboxone were approved by the FDA in 2002. One of the biggest advantages to this was that an average doctor could get trained and be able to prescribe Suboxone or Subutex in the medical clinic without having that special designation for methadone.
Currently that training is a six hour online training. And then you get a waiver where you can prescribe up to a certain number of patients at a time on Suboxone or Subutex. The level of waivers can be 30 patients to 240 patients. It may have shifted since I last was looking at it. But that’s in general what the waivers are like.
While methadone is a Schedule II drug, buprenorphine is considered Schedule III denoting it as a drug with a lower abuse potential. Buprenorphine was originally used as a pain reliever because it is an opioid. When taken as directed, there is not a euphoric effect.
That’s not to say that it can’t be abused. It absolutely can be abused. Someone could take Suboxone and get high from it as long as they don’t have a strong opiate dependence. Because if they did, it’s just not going to be strong enough.
Buprenorphine is described as a long acting, high affinity, partial agonist. Because of its long acting abilities, it helps stabilize opioid receptors, reduce cravings and prevents withdrawal.
As a high affinity opioid it blocks the opiate receptor from from other types of opioids, reducing the potential for abuse of other opioids. The partial agonist means that it has a ceiling in terms of how high you could get from it and a low overdose risk.
So Subutex was the first one that was formulated. Subutex is simply buprenorphine. There’s nothing else involved. Suboxone on the other hand is buprenorphine plus Naloxone. We’ll get into Naloxone in a little bit, but Naloxone is the antidote to opioid overdose.
Subutex was found to be pretty effective. However, there was still a tendency to abuse the drug. Which is why Suboxone has become pretty much the medication of choice here since it has the addition of Naloxone in it which helps with that ceiling to prevent overdose and abuse.
It can be abused, however. As we talked about in the last episode, it’s built so that you can’t inject it, but addicts are really creative. And of course they found a way to do it. It’s not going to be super common and yes, you can buy it on the street, but there is a limited supply because nobody has figured out how to make a pressed pill of Suboxone.
One of the things I’ve seen is that there are people who are addicted to pills or heroin, and they’ll buy Suboxone off the street to try to manage their addiction and get themselves on Suboxone without having to go to the doctor and get a prescription. Some people don’t want to go to the doctor and because they don’t have insurance, some people don’t want to go because they’re afraid of the stigma. Some people don’t want to go because if they were found to be on Suboxone, they could lose their job. Such as anyone in the military.
If someone in the military is found to be on Suboxone or needing Suboxone, they’re going to lose their job. This puts a lot of addicts in a difficult situation because the flow of medication onto the street is really erratic.
There are absolutely Suboxone farms, just like there were pill farms. Where you can just go in, get your max dose, which is usually like 36 milligrams. And you can split it up and sell that. Suboxone is a little better regulated and I do think that the existence of those farms isn’t necessarily as high as it was with pills. But that’s sort of my opinion and just what I hear on the street. So it could be very different wherever you live.
I’m going to use the word Suboxone, because that’s typically what it’s going to be, even though the generic is buprenorphine. And then we have the version of Subutex versus Suboxone. Subutex is just buprenorphine. Suboxone has both buprenorphine and Naloxone in it. Most doctors are probably going to use the Suboxone because it has the Naloxone in it.
But there are cases to use Subutex with pregnant women. This is what I meant earlier when I said that we used to use methadone for pregnant women because it was safer. Now we use Subutex for the most part, because that’s another alternative that will do the same thing, but doesn’t totally block the opioid receptor.
You can imagine that going in to have a baby, you’re going to need to be able to have pain medications on board. However, this requires that labor and delivery and follow up are willing to follow the treatment plan and make sure that the mother has given her medication as prescribed while in the hospital. We found this to be a little difficult and there is a stigma for people on these medications and especially mothers on these medications.
The baby may develop Neonatal Abstinence Syndrome or NAS as a result of the mother’s use of Subutex. It doesn’t happen to all babies, but it definitely does happen. It can take a couple days after birth to appear and could last more than two weeks. It can be managed though. Again, we need the teams in the OB departments to be willing to work with these mothers and be trained on how to help them.
The difficulty I’ve seen in working with hospital departments isn’t necessarily about resistance. Hospital systems are just so entirely different from clinics and they have their own protocols and their own way of doing things. Getting them to consider implementing new protocols or standardizing care for mothers who are on opiates or Subutex can be challenging.
I do think it’s probably going to move in that direction because this is something that we have a lot of research about and is becoming something that they increasingly need to know, especially as access to treatment increases.
Both Subutex and Suboxone are taken in a sublingual manner. Meaning that the strip or the tablet is placed under the person’s tongue. Subutex tends to be a pill where Suboxone is a strip. So think about it like a Listerine strip. So they’re a film and you cut off the part that you need. They typically come in eight milligram strips and you would take however many milligrams you’re taking a day.
Just for reference the biggest dose I’ve heard of is 36 milligrams a day. Which is an incredible amount. The clinic I worked in previously had a top limit of 24 milligrams that they wouldn’t go over. Most people are going to be on maybe eight milligrams, 12 milligrams, that kind of thing, possibly a little more, we try to keep it as low as we can. Even a drop of two milligrams is gonna cause discomfort and withdrawal. So the taper off of something like Suboxone is going to be really slow. .
In order for someone to get on Suboxone, this is sort of how it rolls. A person has a substance abuse assessment, right? That’s chemical dependency assessment by a counselor or a therapist. Then they go see the physician or the nurse practitioner or the PA who is going to be prescribing. And then they set an induction day or date.
So a person has to abstain from opioids for about 12 to 24 hours before they start. It’s pretty important that they’re honest with the medical team that’s going to be inducting them on Suboxone because if they’ve been using, they’re going to find out that it puts them into pretty significant withdrawal because of the addition of Naloxone into their system.
That is acute withdrawal and that sucks. I have seen patients come in and lie about when they last used and they are in serious trouble. Not like life-threatening trouble, but just a hurting unit because of the acute withdrawal. They’ve been through withdrawal before, but this was forced. Naloxone as we’ll talk about immediately rips the opiate off the receptor. You go from feeling the calm euphoria of being high to in instant pain and withdrawal at its height. And it sucks.
For long acting, it’s going to be more like two days, which is really difficult for people. Oftentimes if they know that there’s going to be relief, they’re able to do it. So on the day that they have their induction. If there’s a pharmacy onsite, then they’ll be able to get their prescription there.
If there’s not a pharmacy onsite, then they have to go to their pharmacy, pick up the prescription and then show up at the clinic. So there could be some problems there and you would think, well, wouldn’t someone just go get the prescription and then take off with it. Yeah, they could and then the clinic’s never going to see ’em again.
So typically that doesn’t happen. In my experience we didn’t have trouble with that. The people who are doing this and are going through the steps of it really do want this to work. They know that if they take off with that prescription, that they don’t get a second chance and I haven’t seen them divert it. I’m certain that it happens. It’s just not a high rate of people doing that.
So the prescription has to be brought to the clinic or gotten from the pharmacy at the clinic. It’s given to the medical team and the person’s going to be there for probably six to eight hours that day. So they start with a two milligram tab and every hour they’re getting checked by a nurse or by the prescribing person. They’re doing an assessment of their withdrawal syndromes called a COWS score which stands for clinical opiate withdrawal scale. it combines subjective symptoms with objective symptoms.
They’re given their second dose, which increases by two or four milligrams depending and this continues throughout the day until they get to the place where they’re more stabilized and they’re able to go home. So typically they’re going to come back the next day and check in or the following day. A person who is on Suboxone is going to see their provider pretty often in the beginning.
Sometimes someone can be taking part of their dose in the morning and part in the afternoon. Think about how Adderall kind of wears off for certain kids and then you have to take a second dose; kind of like that. Ideally we’d like it to be once a day. Part of that is just that taking things whenever you feel distressed, isn’t necessarily the kind of medication regimen that we want.
Addicts and alcoholics are really used to taking things when they feel shitty. We want them to get used to taking it in the morning and then just moving through their day. However, if they’re waking up in withdrawal every night, we need to adjust that. The prescribing person will work with them on that.
Here’s where we jump into opinion. Certainly there are studies supporting this, but I want to be real clear that this is my opinion as a person in recovery, as a person who is a substance abuse counselor and as someone who has run a clinic that did Suboxone.
I believe Suboxone needs to have a treatment component with it, always. When someone is getting on Suboxone, this is not a cakewalk, Suboxone isn’t necessarily pleasant. There’s a lot of sexual side effects. There’s a lot of gastrointestinal issues. Like this doesn’t feel good, so it’s not necessarily some kind of reward or like, yep I’m all good now.
I really believe that they need treatment. Like. Outpatient groups, individuals, psycho-education all the things that go along with that to help build a recovery plan. I am not a fan of places that do Suboxone and people just walk out and go on with their day. Yeah, it might work. But there’s a reason that they got into using and why it got out of hand.
They need to have a chance to evaluate that and work through some of those issues in a supported environment. I also believe that there need to be drug tests that are kind of standard when it comes to Suboxone. And for the most part there are. Just because someone’s on Suboxone, doesn’t mean that they’re not having issues with cravings to use.
Now they might not be craving opiates necessarily, but there are a lot of triggers for emotional stuff that they may be having trouble with. Maybe they feel like they can drink alcohol. Maybe they feel like they can smoke weed. Maybe they think that they can use other things.
Doctors, nurse practitioners, and PAs went into this business because they want to help people. It is not their job though, to do the treatment. That’s our job or the job of a substance abuse counselor. I firmly believe that a comprehensive program is the best bet. I really have strong opinions about places that just do it, where you go in, get your prescription, and then you’re out.
One such place opened up in our area and it was super hard for me and my team, because we had worked really hard to create a really solid program where we were the place that if you were really serious about getting clean, that’s where you went. We were really proud of that aspect.
I think sometimes it might’ve been seen as though we might be too “strict”, but the clients would tell us that they knew that we were taking it seriously and that we were going to walk with them all the way. It was a safe place where we worked to keep people on their path that they chose.
Having a place in town where you could just go and you pay cash, or you could use your insurance in some cases to get this medication and just be off with it. That was difficult, but also not our circus. I think Suboxone is the best bet when we’re talking about maintenance therapies.
Medication Assisted Treatment: Naltrexone
Next, we’re going to be talking about naltrexone. This is different than the naloxone. Naltrexone is a medication that has been around awhile. I’ve seen it used in a number of different capacities, and they’re still doing research on potential uses.
For our context naltrexone is an antagonist. Naltrexone works to block the opioid receptor by competitive binding. It’s indicated for use in opioid dependence and alcohol dependence because it’s opioid receptor blockade secondarily diminishes the dopamine activity that is otherwise enhanced by alcohol.
Naltrexone is typically taken in pill form at 50 milligrams a day and has to be taken every day in order for it to work effectively. Naltrexone blocks the opiate receptor so that you cannot get high from opiates. It is an excellent choice. This is not something that is abusable, it’s kind of like the least abusable drug on the planet.
Nobody wants to buy this on the street. If you take naltrexone while you are on an opiate, you will go into withdrawal as soon as it hits your bloodstream. As we talked before, acute withdrawal sucks.
Naltrexone can be a really great option for people who don’t want to go the maintenance route and who are ready to get off of the opiates completely. One of the down sides though, is that you have to take it every day. So there’s a medication also called Antabuse that they’ve used for alcohol use disorder, too. You have to take it every day and if you drink, it makes you sick. The trouble is, is that as addict and alcoholic, you can just choose not to take it wait enough days or however long it is so that you can use.
Taking something every day is you choosing every day that you’re not going to use that day. Some days you might not feel as strong as others. So they came up with another form of naltrexone in a shot version. So this shot lasts for about 28 to 30 days and you do it once a month. It’s called Vivitrol.
Vivitrol is a brand name and it’s really expensive. It’s like a thousand dollars a shot. Insurance does cover it in some cases and in other cases not. So their push has been to get a lot of state Medicaid and the Medicare program to accept Vivitrol as an option. I think Vivitrol is great.
You choose once a month to get the shot and then even if you want to use opiates later in the month, you kind of have to wait until you’re due for your next shot. By then hopefully those cravings will have passed. Yes, people can use other drugs and other substances, which is why I think that treatment programs are really necessary.
If not a treatment program, per se, then seeing a therapist that feels like they can work with substance use and cravings as well. The price is one of the issues with Vivitrol. Secondarily, if there’s no pharmacy at your clinic, then somehow that medication has to get to the clinic so that it can be administered. Not insurmountable, just a complication.
So some people might be thinking, well then why doesn’t everyone go on naltrexone or Vivitrol? Over my career. I’ve had a chance to listen to and staff a ton of cases, and we make recommendations for what we think somebody might need.
Ultimately, they get to choose if they want to be on Suboxone or if they want to be on naltrexone. I’m not necessarily saying that everyone who wants Suboxone is going to get Suboxone, because there are people who come in, tell us they have an opiate habit and they might not actually. There are going to be things that have to be in place to kind of catch those things.
Naltrexone is one of those things that I think a lot of people feel like when they’ve been on Suboxone, and they’re tapering down that they want to use naltrexone because it does stop the cravings once you’re off of it. So you could go off Suboxone and then your opiate receptors are just open and no binding to it and they could be screaming at you.
Once you get off Suboxone, it’s not like your opiate receptors are just normal. You’ve been on an opiate. I think naltrexone is a great option at that point, to be able to make sure that your opiate receptors aren’t driving you nuts.
Also for people who’ve been able to maintain some level of sobriety, whether they’re able to pull a week or two weeks or three weeks together, re-inducting them on Suboxone may not be the best idea.
They’ve gone through the worst of the withdrawal. Their body’s starting to get a little more normal. Their gastrointestinal system is starting to turn around and re-inducting them means they’re gonna get high if they’ve been off of it. There are some instances where we might want to do that. For instance, if someone does really high risk things like they just overdosed and nearly died or overdose a lot and end up needing Narcan a lot to come back, that’s really risky.
Having them on Suboxone means they’re not going to overdose and we can keep them alive longer to help them figure out why they’re doing that. It’s very complicated in terms of what someone should be on and why, and very individualized. The moral of the story is that we have a wide array of options, in my opinion, for treating opiate use disorder.
We have methadone for people who are really heavy users who couldn’t be on Suboxone right now because their dose of heroin and then methadone is too high. But we can move in that direction. You’ve got Subutex for pregnant mothers. We’ve got Suboxone for everyone else. We have naltrexone in pill form for those whose insurance doesn’t cover it. Or we have the shot form for those who do. We have a full spectrum here for opiate use disorders that I think is really exciting.
It is long and it is involving a lot of services, but our research does show us that people need support in recovery. If a clinic is doing it well, it can be a really neat experience. We slowly taper down what’s happening at the clinic and in treatment and encourage them to build a recovery network outside of the clinic. So they don’t have all their eggs in that particular basket. So to speak.
You can probably tell I’m pretty passionate about this because I’ve seen it work and I’ve seen it change people’s lives., I’ve seen it give people back their family members and I’ve seen it keep people alive when they definitely wouldn’t have been otherwise.
I also firmly believe that it has to be done appropriately and with integrity. There’s too much room for cutting corners, corruption, and the program just becoming a joke without there being good structure and people who are committed to the program.
Medication Assisted Treatment: Naloxone
The last thing we’ll talk about today is Naloxone. On the spectrum. Naloxone is even further than naltrexone. Naloxone’s whole purpose is to immediately unbind the opiates from the receptor. Naloxone has saved countless lives all over the world. As we talked about before, the way opiate overdose kills you is respiratory depression and brain hypoxia.
Once someone stops breathing, you have a very short window to bring them back. Somebody has to be there in order to administer the Narcan. The brand name of Naloxone is called Narcan. A lot of times you’ll just hear people talk about Narcan and that’s what we mean, Naloxone.
Three versions of Naloxone approved by the FDA. One is an auto-injector think like an epi pen kind of thing that has Naloxone in it. These are expensive and not typically terribly common for average people let alone addicts to be carrying, but they do exist. Then there’s the nasal spray and acts just like an average nasal spray would. The person administers it to them and it does its thing. The last way is an injectable that you have to draw up into a needle yourself, and you’re injecting this into a person, not into a vein, and not into their heart pulp fiction style.
Naloxone is an extremely safe medication. It only affects people who have opioids in their system. That is a huge benefit because if you see somebody nodding out, flopping on the floor, not breathing, you can administer Narcan without worrying that you’re going to hurt them. You’re only guessing that it’s opiates, you could be wrong or not, but if you’re wrong and it’s not opiates, no harm, no foul. If you’re right, then you just saved this person’s life. I know it’s scary for people to think about administering Narcan and it’s pretty scary to watch someone die in front of you.
I have stories of people I know who have been able to administer Narcan to a stranger and save their lives. I think Narcan is something that we need in our clinics and that we need in more than just medical places and therapy places. I think it should be as common as having a defibrillator.
All across the country, law enforcement, first responders, fire departments are carrying Narcan. Some enthusiastically and some not. There is a lot of stigma about being an addict or an opiate addict or a junkie or whatever word they want to use. Where they feel like. Why would I want to save one of them? That’s a literal quote that I’ve heard a professional say.
You can get Narcan from a lot of places. Typically it’s going to be the injectable form without the auto inject, because that’s the cheaper form. You can get that from needle exchanges, you can get it from pharmacies like CVS. You can get it with and without a prescription, sometimes insurance will cover it. It just sort of depends.
Family members can have it. If you have a client who has a family member that has an opiate addict. They should have this and they should get trained on how to use it. There are lots of ways to get trained and it’s all over the place that you can figure out how to use it and how to get it.
People who are in the prevention world for opiate overdose are more than happy to share their knowledge and to help you get Narcan. At my previous clinic, we had Narcan in nasal form and we were all trained, even the front desk staff, on how to use it.
So if you want to know in your area, I encourage you to just do a little Google search, ask your local health department. Look for whoever’s doing this kind of prevention work in your community and get some Narcan on hand.
We have a ton of options for opiate use disorders, and it is nothing short of a miracle to me. We can take them from really high doses of opiates, all the way down to quieting their receptors with the use of naltrexone.
The answer to the opiate epidemic is not to leave people unassisted. We want these treatment programs to be full. We want treatment programs to be covered by insurances. We want there to be funding, to cover people who need inpatient treatment first. We as therapists have a key role here in helping people in their recovery.
If someone’s on Suboxone and they’re in your office, they’re sober. They can do work. They could do EMDR. They could do lots of things. But they have a chance to do it with support. Your role as a therapist is huge. You may not have an official treatment program in your area, but there are medical professionals in your area who prescribe Suboxone. I guarantee it.
You definitely could decide to work with these people. It doesn’t take a lot. You don’t have to know everything there is about addiction. You’ve got a person in your office who has this amazing medication on board, and they want to be better.
You have the tools to help them. I really hope that those of you listening are open to the possibility of doing this kind of work. If you have someone you know is using opiates, do a little research and find out who’s doing the Suboxone. talk to their clinic manager, or one of the nurses to find out what their process is. You could bring this up to your patient and help them understand what their options are. People do not have to live a life imprisoned to opiates. There is a way out.
So for the next two weeks, we’re going to be doing something a little different. Full disclosure: this is because I’m going to take a break. Not just from the podcast, but it’s spring break around here. While my children are grown, I’m still on a school schedule pretty much. I’m going to take a week off.
And so that means not recording, not editing, not planning and not doing all the other things that I would normally do. So there will be two podcasts going up on our usual day. One is a repost of an interview I did with Shrink Rap Radio. Dr. Dave has been podcasting for over 15 years.
I was episode number 727, which is mind blowing to me. There are people all over the world that listened to his podcasts. So that’s going to go up.
The second Monday a podcast is going to go up that I did with a guy who does a gambling podcast. He is a gambling addict in recovery who’s been doing a podcast since 2015. It’s called All In: The Addicted Gamblers Podcast. I had a great time talking with Brian and I don’t know if a lot of you got a chance to hear it. Both have been edited down a little bit for time. Those will go up just like normal at 7:00 AM on the Monday morning central standard time.
On March 29th, we’re going to continue our series of talking about different substances of abuse, their implications and treatment. Hope to see you then.
Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.
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