“I want you to understand, I am not an addict,” Rebecca (not her real name), a 32-year-old social worker calling from Philadelphia, spoke emphatically into the phone.
“The pain I have is 100% legitimate and I work with a pain management specialist who is well respected. He warned me that if I spoke to a detox center, they would pigeonhole me as an addict. I simply can’t get off my pain medication by myself; I have tried and tried, and I get too ill…and then I give up.”
She was quiet for a moment and then softly began to cry. “My husband and I want to have a baby and I don’t want to be on this damn medication if I get pregnant.”
Getting Started with Prescription Drug Detox
Rebecca was calling to find out details about an Accelerated Opioid Detox at the Coleman Institute for Addiction Medicine in Richmond, VA. She explained to me that for over twelve years, she had suffered with extreme pain from endometriosis and the various interventions and surgeries done to mitigate the condition. She worked closely with her pain management physician in Philadelphia, who responsibly prescribed her medication. Over the years Rebecca took anywhere from 40mg to a maximum of 100mg of oxycodone a day, depending on the intensity of the pain during flare-ups and following painful procedures.
Over the last two years, Rebecca noted that she was taking the medication more regularly than in previous years. Her current daily dose had stabilized at about 80mg most days, but she realized she was developing a tolerance at this dose, and it often felt like she needed more. She emphasized that she never took more than prescribed and always consulted her doctor before attempting any dose change.
But taking 80mg a day was making her nervous and depressed. She didn’t want the pain, but she didn’t want to be dependent. Earlier in the year she had traveled out of town with her husband and had forgotten to pack her oxycodone. Several hours into the trip she began to feel fever, chills, nausea, and diarrhea, and thought she was coming down with the flu when she realized she was experiencing withdrawal. Unable to find any other solution, they had had to curtail their plans and return home. Rebecca spent an entire visit discussing this with her doctor and even when she attempted to cut down with his assistance, she experienced withdrawal symptoms.
During this discussion with Rebecca, I had a powerful insight at how much courage it must have taken for her to make inquiries at a place with the words Addiction Medicine in its title.
Words matter.
Opioid Use Disorder (OUD) is a specific diagnosis. So is Opioid Dependence.
UNDERSTANDING ACCELERATED OPIOID DETOX
The Stigma of Opioid Use Disorder and Addiction
A person diagnosed with OUD may continue to use opioids despite the use of the drug causing relationship or social problems. They may fail to carry out important roles at home, work, or school because of opioid use. Often, they will spend a lot of time seeking, obtaining, taking, or recovering from the effects of opioid drugs. They will take more than intended and may continue to take them even knowing that this is causing a physical or psychological problem.
Rebecca did not fall into this category; she was not drug-seeking or displaying aberrant or problematic behavior. She never failed a urine drug screen, and she never took her medications other than prescribed. She was, however, developing a tolerance to the medication because that is how opioids work. Tolerance means an increased dosage is needed to produce a specific effect.
I had never really considered the fact that the name of our business might discourage people with uncomplicated opioid dependence to reach out for help, turned off by the thought that our staff would automatically categorize anyone coming here as an ‘addict’ or someone with a substance use disorder.
The Coleman Method for Prescription Drug Dependency
In truth, over the almost 19 years I have worked at the Coleman Institute, I suspect roughly a third of our patients have come here to receive help getting off their pain medication. One of my very first, very memorable patients, was a resilient man in his late forties who was the survivor of a rare type of abdominal cancer. He had had multiple surgeries and was in remission. His treatment included several pain medications and while he had managed to wean himself down, he was stuck on a very small amount of prescribed transdermal fentanyl. Try as he may, he could not get off this 25mcg dose without becoming violently ill. He detoxed beautifully with a three-day outpatient detox procedure. Since that time, I have been able to participate in hundreds of successful Accelerated Opioid Detoxes for people wanting to get off their pain medication--people who have been taking their meds precisely as prescribed by their doctors.
It is certainly true that we also treat many patients for OUD who started out being prescribed pain medications and for a variety of reasons, they were unable to continue getting their medicine. Sometimes their prescribers have lost the privilege to prescribe, sometimes the offices have simply closed. Others were prescribed by their primary care providers who then decided they no longer wished to participate in pain management. In smaller cities or rural areas, it can be very difficult to find a pain management specialist. In some of these cases, our patients found alternative ways to get their medication, desperate not to suffer terrible withdrawal. Much of the illicit pain medicine is fentanyl, pressed into pills that look so realistic, it is even difficult for a pharmacist to tell it from a legitimate pill.
Respect and Results for Patients
My colleagues and I who work to help patients get off opioids understand that whether a person is physically dependent on legal or illegal opioids, getting off of them is difficult, and we have the highest respect and regard for each and every patient and their specific situation. The Coleman Institute provides a minimum of five comfort meds, given around the clock to help make this process as tolerable as it can possibly be.
Since ours is an outpatient procedure, patients bring their own support person with them. Depending on the type and amount of opioid being taken, and other medical conditions, our detoxes are usually between 3 to 8 days duration. Rather than ‘ease’ someone onto methadone or Suboxone, the Coleman Institute specializes in clearing the opioids out of the system and getting patients onto long-acting naltrexone, which is a non-addictive opioid-blocking agent, curtailing the cravings for opioids.
We believe in using long-acting naltrexone because once opioids are stopped, the brain needs to heal. People are vulnerable and may experience Post-Acute Withdrawal Symptoms (PAWS) or find themselves extra emotional and not quite sure how to handle it. It can be very tempting to return to the opioid during this period, but if naltrexone is on board, the opioid receptors will be blocked or occupied, and opioids will have no effect. It is very protective to use long-acting naltrexone during this time.
Even if our patients have simply been taking pain medication and do not have the diagnosis of Opioid Use Disorder, the support of good follow up can make a big difference in the long-term success of staying opioid free. The Coleman Institute provides six months of naltrexone therapy and case management for the duration of treatment at select offices including our Richmond, VA location. Many of our patients have opted to continue treatment for months or years following their detox.
Rebecca and I spoke for a long time, and I provided all the information I could, so she had a good understanding of our program. I think by the end of our conversation she was reassured that no one in our office would assume she was a ‘drug abuser’. She is signed up to come in next month, with her husband as her support person.
I do hope you or a loved one won’t be put off by seeing the words Addiction Medicine in our title if you need help to get off pain medication. We are happy to answer all your questions, so please give us a call.
Take care,
Joan Shepherd, FNP
