"I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear." — Nelson Mandela
My day job connects me with some of the bravest people on the planet. These are people who have—for any number of reasons—become ensnared by opioids and their exhaustive power to consume life.
But these same people are at the Coleman Institute for Addiction Medicine to receive help and start over.
I haven’t experienced opioid withdrawal myself, but I have witnessed it many times, and I have listened to many stories. People are aptly terrified anticipating a cold turkey detox, so I’m particularly gratified to reassure my patients that choosing our accelerated or rapid opioid detox program to get off these substances (Roxicodone®, Vicodin®, hydrocodone, morphine, fentanyl, hydromorphone, heroin, kratom, buprenorphine, or methadone etc…) can help them through the worst of the physical symptoms so they can launch themselves back into the lives they were meant to have.
Naltrexone is one of the top three medications used to treat Substance Use Disorder (SUD) for opioids. The Coleman Institute for Addiction Medicine has specialized in helping people get on naltrexone for over 20 years.
Naltrexone is a pure opioid antagonist, which simply means it sits on the opioid receptors. It does not cause physical tolerance, so dependence doesn’t develop. There are no withdrawals when one stops using naltrexone.
Sounds perfect, right?
The problem is, the opiate receptors in the body must be clear of the drugs before induction onto naltrexone. Otherwise, the naltrexone comes in and sweeps the opioids off, and can precipitate severe withdrawal.
With that in mind, these are 5 things you should know before starting on naltrexone therapy:
1. It is imperative to have the opioid receptors clean when starting on naltrexone.
As I mentioned earlier, in order to induct a person onto naltrexone, whether daily oral tablets, a monthly injection, or a long-acting naltrexone implant, the opioid receptors must be free of opioids.
This is the biggest challenge in getting a person onto the naltrexone, and this is why, if you are ready to use a pure agonist for treatment, it is so helpful to work with an educated medical professional.
I have seen patients be given naltrexone too early and seen them forever swear it off because of the precipitated withdrawal it caused. At the Coleman Institute, we use a minimum of five ancillary medications to ease people off the opioids. By the end of the detox period, between 3 and 8 days depending on the drug(s) being detoxed, we know it is safe to begin the naltrexone.
2. Once someone has been completely detoxed off of opioids, they are at high risk for overdose when the naltrexone wears off.
This is perhaps the most ardently emphasized teaching point as we transition people from opioids to naltrexone.
A person on daily opioids develops a tolerance and needs higher doses of the same medication to achieve the same result. (This is also true of benzodiazepines and alcohol.) When the naltrexone implant wears off between 8 and 12 weeks, or the naltrexone injection (Vivitrol) in 3-4 weeks, the patient who uses opioid substances, particularly IV, is as vulnerable to over-dose as someone who is using for the first time.
This is why we encourage our patients to commit to at least a year of naltrexone therapy while concurrently attending some type of addiction counseling.
3. Liver enzymes should be monitored.
I am including this because many people worry about their liver when they start naltrexone. At the Coleman Institute, we always measure liver enzymes when we start someone on this medication, and we re-check the levels at subsequent visits.
I can remember only one patient (in hundreds) for whom we stopped the naltrexone due to elevated liver enzymes, and this patient’s enzymes were reflective of liver damage due to years of very heavy drinking.
All medications are metabolized by the liver or kidney; that’s their job. Do not confuse the fact that a medication is metabolized by the liver with a medication damaging the liver.
4. Be prepared to have no physical cravings for opioids.
This may seem like an odd thing to include in a warning, but many people who have long depended on the mind-altering impressionistic world they’ve existed in for so long on opioids, find the transition to reality a bit stark and, well—boring.
This is why I cannot stress enough here the importance of working with the best therapist, or group counseling or recovery meetings you can find. Boredom is a huge trigger for relapse, and over the years I have seen it topple the most enthusiastic patients.
Ponder the idea of the arrogance of boredom for a moment: is there truly nothing new the world has to fascinate you?? But until that monkey is off your back, there is no way to appreciate anything but how to not be sick.
5. Be sure to carry a medical card letting people know you are on naltrexone in case you are in an accident.
Morphine based pain medications won’t be effective, and you want the medical team to know they will need to use alternatives to provide pain relief.
Similarly, if you are on a long-acting naltrexone formulation and anticipate surgery or a medical procedure that may require the use of pain medication, let your provider know. We frequently counsel people on the best way to use the smallest amount of narcotics for the briefest period of time if they must have it.
We have conducted some 2nd and even 3rd accelerated opioid detoxes on people who have not been well prepared for surgery and became dependent again on opioid medications for pain management, starting the devastating cycle anew.
Many of my patients in long-term recovery are adamant about having a discussion with dentists or other medical providers informing them that under no circumstances are they to be prescribed pain medications. (I recall a patient who had breast augmentation surgery and refused opioid meds!)
When you or your loved one is ready to tackle the issue of stopping opioids, give us a call to discuss your particular situation. In some cases, insurance covers most of the treatment. It is a brave first step, and you won’t be walking it alone.
Joan R. Shepherd, FNP
