Claire (not her real name) juggles a lot in her life.

  • She is a full-time college student.
  • She works part-time.
  • She is getting married over Thanksgiving.
  • She has an opioid addiction.

How Claire Got Here

Her first attempt to complete college failed when she started using pills at age 20. She never believed the occasional pill she took to catch a little buzz would ever result in her life being completely undermined. She quickly developed a tolerance and started using it daily. She was caught with drugs and detoxed in jail.

When she left jail she did a 30-day treatment program. She was pretty involved in recovery Meetings for the first several months, but as time went on, she felt less of a need to attend. She worked, met Tommy, a nice guy — who had no experience with drugs — and she told me she started to think of herself as someone who really wasn't an addict. She drank a little with her friends and smoked some pot from time to time. She decided to return to school to complete her degree and she and Tommy set a date for their wedding.

But then stress happened.

How Stress Impacts Relapse

The pressures of being back in school full time while continuing to work were worse than Claire anticipated. She started drinking regularly to relieve the mounting anxiety she felt with her intense schedule, as well as planning a wedding. Drinking escalated to several drinks daily. She was sleeping poorly and waking up feeling horrible. Memories of previous failures in school haunted her. She felt like she was on a slippery slope.

It wasn’t long before she turned to pills. She reasoned that using opiates briefly would help her stop the cycle of drinking she found herself in. Pills, difficult to find and very expensive, quickly turned to heroin.

Fortunately, Claire came to see us after only a couple of months of heroin use. She wanted to be on long-acting naltrexone, which had worked for her in the past.


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The Dangers of Relapse in Stressful Times

When Dr. Coleman talks about why people relapse, dealing with strong emotions is always a front runner.

A person who has not developed the skills of coping with difficult situations or feelings, may naturally turn to a substance or behavior in times of stress, rather than actually dealing with the problem. The instant relief that may accompany this strategy can create the foundations of physical dependence on an addictive substance, and a lifetime of not learning how to successfully navigate reality. Even people who have achieved some degree of recovery are at risk of relapse if they are confronted with an unresolved situation or have continuously buried unacknowledged feelings.

How Naltrexone Therapy Works

Naltrexone is an opiate antagonist, or blocker. When it's in a person's body, it prevents opiates from having a place to "land." The naltrexone occupies the opioid receptors, but doesn’t cause euphoria and doesn’t create physical dependence. It is available in two long-acting formulations, a monthly injection called Vivitrol or an implant that lasts, for most people, about two months.

Her insurance covered Vivitrol, but in order to use naltrexone the opiates must be out of the body, otherwise, it will precipitate withdrawal. Going cold turkey wasn't an option. We prescribed several 2/0.5 mg Suboxone strips for Claire and created a tapering schedule to have her completely off within two weeks. Before she could get the Vivitrol, she needed two more weeks free of Suboxone. This was the most worrisome part of our plan, leaving her vulnerable to relapse.

The Difference Between Naltrexone and Suboxone?

Currently there are three Medication-Assisted Treatments (MATs) for someone with an Opioid Use Disorder (OUD).

Methadone is a long-acting opioid to help people stop using short-acting drugs, whether it’s heroin, fentanyl, or even prescription pain medications. Being on this type of treatment typically involves daily visits to a methadone clinic. These treatment programs work with their clients to get them to a dose of methadone that stops the cravings for short-acting opioids. Many of these treatment programs offer (and/or require) counseling. By requiring a daily visit, people whose lives were marked by chaos may finally have some structure.

Suboxone and other buprenorphine-containing medications are another form of MAT for a person struggling with opioid addiction. Unlike methadone, buprenorphine is considered a partial opioid; it occupies the same receptors in the brain that methadone and other opioids (like heroin, fentanyl, oxycodone, hydrocodone, hydromorphone, oxymorphone, morphine, tramadol, etc) occupy, but it binds more strongly to the receptors than the short-acting opiates/opioids, blocking their effects, without fully activating them. This means that the effect of Suboxone is less strong, so people don't get high from it, or at least much less high. This allows the drug to block withdrawal and reduce the craving for opioids.

It is a highly controlled substance, and different treatment programs and insurance companies have different requirements for patients. Most people who decide to use this type of MAT will need to go to their clinic weekly at the beginning, then every other week, and sometimes they will be able to get prescribed a month at a time. I remember when this medication first came on the market, it was referred to as the “white-collar-methadone” because people did not have to come to a clinic daily and could be prescribed a month at a time. Since the opioid crisis, however, there are stricter regulations governing how this medication can be prescribed.

Like other forms of MAT, clinics may require counseling, random urine screening, and pill counts to be sure the patient is in compliance. Although for many people, this is far more convenient than daily dosing at a methadone clinic, getting to a clinic weekly or twice a month can create challenges around work schedules or for people with transportation issues.

Importantly, because both methadone and Suboxone are opioids or partial opioids, abrupt cessation can cause severe withdrawal symptoms.

Naltrexone is the third form of MAT. Unlike the two previous treatments, naltrexone binds to the opiate receptor as if it were an opiate, but it doesn’t "turn on the switch." Instead, it acts as a pure blocking agent. We frequently use the image of a magnetized key going into its corresponding lock to describe the action of naltrexone as it binds tightly to the receptor, occupying the receptor and preventing the possibility of a competing short-acting drug (like heroin, fentanyl, or oxycodone) a place to "land." Being a pure blocker, naltrexone does not cause physical dependence, so when the naltrexone wears off, there are no withdrawal symptoms.

How Claire Found Recovery

Claire met with our Recovery Support Specialist, Bridget Walsh, and together they came up with a plan to keep her accountable and opiate free during those two weeks. In Richmond, students at VCU have access to excellent Collegiate Recovery resources through the Rams In Recovery program. Claire contacted them as well as a counselor specifically recommended by Bridget to deal with some other issues Claire was facing.

Two weeks later, Claire returned to the office and received her Vivitrol injection. At the time I am writing this article, she remains opiate-free.

How The Coleman Institute Can Help with Switching from Suboxone® to Naltrexone

The Coleman Institute for Addiction Medicine has specialized in using naltrexone for over thirty years. Naltrexone is available in both a daily oral tablet,a monthly injection, or a long-acting implant, which reliably covers the opioid receptors for about two months.

Recovery from an addictive substance can be a complex process and many people dealing with it have a multitude of unique moving parts to manage. By the time a person is in the throes of physical dependence, unraveling oneself may feel overwhelming.

At the Coleman Institute for Addiction Medicine, we are pretty good at breaking down these seemingly insurmountable situations into workable steps. If you or a loved one are struggling to find your own path to freedom from opiates or other addictive substances, please give us a call. If we are not the right fit for you, we can probably steer you toward someone who is.

Joan Shepherd, FNP


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