I started a new patient, Jimmy, for his Accelerated Opioid Detox today. He thought he was coming off heroin, but his urine also revealed fentanyl. . . almost a daily occurrence now at the Coleman Institute. He was here with his father, Bob, who didn't really understand about finding fentanyl in the urine.
A lot of heroin is being mixed with fentanyl, which makes an overdose more likely since it’s so much stronger than heroin. In fact, a neighboring county no longer posts their local overdoses in the newspaper. Turns out when an overdose has happened, people think that’s where to find ‘the good stuff’.
We continued to discuss the detox, which was extended from 4 to 5 days due to the presence of the fentanyl. Throughout the instructions about medications and what to expect over the next few days and weeks, Bob had many questions.
One of the more confusing aspects of figuring out how to help your loved one get off heroin (or Percocet®, Oxycontin, Dilaudid®, Vicodin®, etc.), is understanding the differences in the various forms of MAT (Medication Assisted Treatment) for opioid use disorder.
Maintenance therapy includes methadone and buprenorphine products such as Subutex®, Zubsolv®, and Suboxone, all of which are long-acting opioids. Suboxone and Zubsolv® also include naloxone to help prevent misuse. These medications can create physical dependence or addiction. If a person takes them for an extended period of time, severe withdrawal symptoms occur when a person tries to stop.
Bewildered parents, including Bob, ask incredulously, “Why do they put people on another addictive medicine? Aren’t they trading one drug habit for another?”
Not surprisingly, our patients usually know a lot more about the facts and nuances of the different MATs than their parents (or many medical providers). Jimmy told his dad that he had used Suboxone himself while attempting to get off the heroin, but it didn’t work…when he had the opportunity to use heroin, he simply traded off the Suboxone. Products containing buprenorphine have high street value, as it can stop a person from going into withdrawals.
Suboxone prescribers are numerous and, with recent legislation, doctors can now have up to 250 patients on buprenorphine—previously they were limited to having 30 in their first year of prescribing, and in subsequent years, 100. Additionally, now both nurse practitioners and physician’s assistants may qualify to be buprenorphine prescribers. It is so much more available to people, and it can be as easy as collecting payment and writing a script.
Some addiction practices require their patients on Suboxone (or other forms of Buprenorphine) and methadone to attend counseling, and some insurance companies make this a qualification of covering the cost of the medication.
But for the patient who prefers to not be on another addictive medication, naltrexone is an option. As opposed to a maintenance medication, we think of naltrexone as an abstinence medication, since it not mood-altering and the person taking this medication does not become physically dependent. But before a patient can get on naltrexone, this pure opioid blocker, all the opiates must be out of the system.
Think of it like this:
The opiate receptors are like locks that very specific keys fit into. The keys are any form of long or short acting opioids: Oxycontin, oxycodone, Vicodin®, Opana®, Dilaudid®, fentanyl, heroin, methadone, buprenorphine, etc. Remarkably, naltrexone also fits into this lock, however unlike the opioids, naltrexone doesn’t ‘turn on the switch’. It creates no euphoria and no dependence. It is simply a pure blocker.
In order to populate the receptors with naltrexone, the opioids need to be removed.
This is why people come to the Coleman Institute. When I say the opioids need to be removed from the receptors, what that really means is withdrawal. Anyone who has experienced a cold-turkey withdrawal can tell you what it is like and why they do anything possible to avoid going through it. Many of the patients we see are terrified to go through any process that involves removing opioids from their system.
Dr. Coleman has trained doctors in multiple states now to provide an Accelerated Opioid Detox. By giving minute doses of naltrexone to patients daily, we gradually remove opiates from the receptors. We provide the support person with specific instructions for several medications to help with the withdrawal symptoms, thereby shortening a miserable ten-day to one-month experience down to 3 to 8 days, depending on what our patient has been using.
I generally tell my patients they will experience a couple hours of relative discomfort, and 22 hours of feeling tolerably good.
Please call us if you have any questions about any of this. It can be so confusing to figure out what is the right choice at any given time. Options for people with Substance Use Disorder abound, and we will be happy to answer your questions. We are very confident of our Accelerated Detox programs, but they aren’t for everyone.
Joan R. Shepherd, FNP