I must admit I was a little surprised earlier this week when Bridget Walsh, our Clinical Case Manager and I screened a former patient who wanted to return to The Coleman Institute for Addiction Medicine for a second detox off opioids.
How Relapse Can Happen
It’s not that a second detox off opioids (such as Percocet, Roxicet, Opana, Oxycontin, oxycodone, Lortabs, hydrocodone, tramadol, fentanyl, morphine products, heroin, methadone, etc) is unheard of; people relapse for a variety of reasons. Sometimes it’s caused by an emotional situation the patient didn’t see coming, sometimes it’s a surgery-planned or otherwise—that puts them back on pain medication; sometimes it’s being in the wrong place at the wrong time and not having the coping skills to deal with the situation. Screening someone who has already completed an Accelerated Opioid Detox and relapsed is important for us so we can figure out the next best plan to help this person achieve long-term sobriety.
Neil fell into the last category.
Trying Again
He came to us for a detox off street heroin that turned out to be mostly fentanyl. Prior to using heroin, Neil had become physically addicted to pain medication. His pain management doctor was prescribing some of the medication; Neil was supplementing the meds with pills he purchased on the street.
Neil heard about our five-day program to help detox off short acting opioids in an outpatient setting. This worked well for him; he missed a minimal amount of time from work and his support person, his girlfriend of several years, was available to be with him for the duration. At the completion of his detox, Neil got the naltrexone implant which effectively blocks the opioid receptors for about eight weeks. Neil was grateful and relieved. He was looking forward to returning to a life not driven by chasing dope.
UNDERSTANDING ACCELERATED OPIOID DETOX
The Stress of The Past Effects Future Recovery
When he was due to return to The Coleman Institute for a follow up naltrexone implant two months later, he didn’t make it. Life was busy, he was feeling great. He absolutely knew he never wanted to touch another opioid again, and he felt very firm in his conviction.
Things were going along nicely when one day Neil ran into a guy who had sold him drugs in the past. Neil’s brain responded automatically, recalling the euphoria it had experienced when heroin and fentanyl flooded his brain with dopamine. He purchased a few pills, telling himself he had this under control. Turns out, he didn’t.
The Dangers of Old Habits
Although I am compressing his journey into a few sentences, suffice it to say, Neil’s next few months were a montage of getting high, lying to himself and his loved ones, spending lots of money, and falling into despair. He found a clinic that offered Suboxone and signed up. For several weeks he had the relief of keeping his cravings at bay by taking his daily dose of Suboxone. And yet…he realized he could trade a dose of Suboxone for other drugs if he wanted to get high. When he gave urine tainted with fentanyl at the clinic, he was discharged from the practice and called us.
What surprised me after talking to Neil and hearing about his experiences since we’d last seen him, was that he really didn’t understand the difference between using Suboxone vs. Naltrexone for his opioid use disorder.
The differences are important to understand.Important Differences Between Suboxone and Naltrexone
1. Suboxone and other buprenorphine products create physical dependence, naltrexone does not.Suboxone is a partial agonist and a partial antagonist, containing both buprenorphine and naloxone. This means buprenorphine produces effects such as euphoria or respiratory depression at low to moderate doses, but these effects are weaker than full opioid agonists such as methadone or heroin. When a person takes buprenorphine for a period of time, they will become physically dependent on it (even in quite low doses) and will experience withdrawal symptoms if they stop it. This does not mean Suboxone is the wrong choice. When taken as prescribed, buprenorphine is safe and effective. It can help diminish the effects of physical dependency to short acting opioids, such as withdrawal symptoms and cravings. Buprenorphine can increase safety in cases of overdose.
Because naltrexone is a pure blocking agent, it does not create physical dependence or build up a tolerance to the drug. Naltrexone occupies the opioid receptors, preventing other opioids from having a place to ‘land’. People who chose naltrexone therapy must be made aware that their body is also losing its tolerance to opioids during this period of abstinence. A person who relapses after having detoxed and not having used opioids for a long time is at a higher risk of having a fatal overdose. Accordingly, different forms of Medication Assisted Treatment (MAT) may be appropriate for different people, or for the same person at different stages in his or her life.
2. Suboxone (and other opioids) must be completely out of your system before starting on naltrexone therapy.Many people with an Opioid Use Disorder (OUD) have experienced precipitated withdrawal. This happens when a person takes a substance that pushes opioids off the receptors abruptly. Both buprenorphine and naltrexone, if given too close to a person’s last dose of short acting opioids, can cause precipitated withdrawal.
The reason many people chose naltrexone over Suboxone is that they don’t want to be dependent on another opioid; some people believe it is just ‘trading one addiction for another’. While we strongly support the use of Suboxone for the right patient, our program is one of the few in the country that has the experience in getting people safely and comfortably onto naltrexone. We carefully ‘bump’ the existing opioids off the receptors as we slowly transition to naltrexone. We do this over a three to eight day period, depending on the substances being eliminated and the co-morbidities of the patient.
3. Suboxone is a controlled substance, naltrexone is notPeople who chose to use Suboxone or other buprenorphine products (such as Bunavail, Zubsolv and Cassipa) to treat their Opioid Use Disorder must find a provider who has a special DEA waiver, allowing them to prescribe it. This medication is highly controlled and patients receiving it must comply with strict state and federal guidelines, as well as restrictions and protocols required by specific programs. Patients taking Suboxone must comply with random pill/film counts, regular and random urine drug testing, and should be aware of the consequences of losing these medications or requesting early refills. Most programs require weekly to bi-weekly appointments. Buprenorphine products are not supposed to be prescribed to people who are also taking benzodiazepines such as Ativan (lorazepam), Valium (diazepam), Xanax (alprazolam), or Klonopin (clonazepam)—just to name a few. While all of these measures are in place to help and protect both the patient and the provider, it definitely adds another layer of complexity to using Suboxone to treat an addiction to opioids.
Naltrexone, being a pure blocking agent, does not require a special DEA license. Any practicing medical doctor with a valid license is allowed to prescribe this medication. There is no extra scrutiny at the pharmacy, and a prescription for naltrexone does not show up on a state’s Prescription Monitoring Program. The Coleman Institute has specialized in using naltrexone therapy for over 25 years. We often use long-acting naltrexone in the form of a small tablet placed under the skin in the abdominal area. This will effectively ‘bathe’ the opioid receptors for about eight weeks. Another long-acting form of naltrexone is a monthly injection called Vivitrol, which many insurance companies are covering now.
How The Coleman Institute Can Help with Opioid Use Disorder
Making the decision to stop using opioids requires some knowledge of what each of the choices for Medication Assisted Treatment (MAT) entails. Research shows that MAT is crucial in increasing the odds of long-term success for a person with Opioid Use Disorder. If you are seeking help for yourself or a loved one, please give our Care Advocates a call at 877-773-3869. They can direct you to one of our medical providers to help you wade through the choices; it can be daunting and confusing, especially when the stakes are so high.
Joan Shepherd, FNP
