Oscar* is 26 years old, has a girlfriend of five years and a one-year-old son. He has worked for a well-known delivery company for the better part of four years and has excellent insurance and benefits. Several months ago, he was physically dependent on fentanyl.
When Oscar called the Coleman Institute for Addiction Medicine in Richmond, Va., he told me that he had ‘played around’ with opioids in his teenage years, taking a Percocet or two at parties, and of course, his friends always knew there would be hydrocodone to share whenever anyone had their wisdom teeth removed. He smoked a little cannabis and drank some beer, but rarely overdid it. He was the guy who always had a job and was always a very reliable employee.
When Pain Pills Lead to Dependency
Working in the delivery business is an extremely physical job. Covid caused demand for these types of services to skyrocket and--not surprisingly—a corresponding rise in aches, pains, and injuries among people who work in that business. Oscar somewhat naïvely accepted the occasional pain pill from various colleagues.
A back sprain caused him to miss several days of work, but there was pressure to be back, and he really does love his job. Thinking it would expedite his return to work, Oscar found a colleague who was able to get him about a month’s worth of pain medication.
Oscar found that not only did his back feel better, but his energy was amazing! Suddenly he was breaking his own personal best delivery records, and if he had a pill prior to coming home, he was—in his mind—a better father and partner. Very quickly he was able to justify the use of pain medications to himself. His life seemed better in so many ways.
Of course, Oscar had heard about all the dangers of being on such drugs. Frequently he told himself he should take a ‘drug holiday’ to cleanse his body, but even his denial wasn’t strong enough to recognize that within six to seven hours, if he didn’t have a pill, he’d start sweating and feeling a little queasy.
The colleague supplying him with pills was getting them from someone who got them from someone who got them from someone—who got them prescribed by a doctor. They were pharmaceutical grade pills and actually did contain oxycodone. But then something—the details are unknown to Oscar—broke down the distribution chain. The pills were no longer available.
“It was horrifying,” Oscar told me, “to realize I didn’t just want these pills, I needed them.”
UNDERSTANDING ACCELERATED OPIOID DETOX
Unknowingly Taking Fentanyl
Oscar’s colleague was a resourceful guy and assured Oscar he could find another source. And he did. He provided Oscar with a bottle of small blue pills that were scored and stamped with a letter and a number. Clearly, he told himself, these were legitimate pills, even though they looked slightly different from the previous ones. And the pills were now necessary for Oscar to be able to get through a morning of work. He was less interested in the energy they gave him and more concerned about not getting sick.
“I was disgusted with myself. I had known so many people that had fallen into this trap and I thought I was way too smart for it to happen to me.”
He was spending lots of money on the pills and worse, he was lying to his girlfriend. He started looking around on the internet for possible solutions and was overwhelmed with the barrage of information out there. He started to get suspicious that his pills were not oxycodone, but instead were fentanyl. This was even more terrifying because he was aware that fentanyl is 100 times stronger than morphine and he read that a portion of fentanyl the size of a grain of rice was enough to kill someone with low or no tolerance.
The opioid crisis has rallied many people in our country to respond. Medical treatment for Opioid Use Disorder (OUD) has become more available as fewer restrictions have been placed on medical providers prescribing medication such as Suboxone (buprenorphine/naloxone).
Suboxone is known as a partial agonist because the buprenorphine component will attach to the opiate receptors, keeping a patient from withdrawal. “It can last for a good 24 hours, so a person using this for his OUD does not necessarily need another dose of opioids every few hours to reduce the risk of withdrawal. Methadone is another medication widely available in clinics around the country. Both Suboxone and Methadone are medications that will occupy the opiate receptors and when correctly dosed, relieve the cravings for opioids.
Alternatives to Suboxone and Methadone
The third medication indicated for OUD and the specialty at the Coleman Institute for over twenty-five years is naltrexone.
Naltrexone is a pure opioid blocker or antagonist. It is non-addictive. Although it occupies the opioid receptors like Suboxone and methadone, it doesn’t ‘activate’ the receptor; it simply blocks it. If naltrexone is occupying the receptor, there is no place for an opioid such as fentanyl, oxycodone, hydrocodone, Dilaudid, tramadol, methadone, or Suboxone to attach.
Oscar knew he didn’t want to be on any more medication that would cause physical dependency, so he came from a neighboring state to our office in Richmond.
Getting Off Fentanyl
Getting onto naltrexone means you must first get off the opioids. Our treatment removes the fentanyl (or other opioids) in small increments each day over a period of 3 to 8 days, depending on what drug is being removed and what other co-morbidities a patient may have. Since Oscar is a healthy 26-year-old man, he was booked for a six-day outpatient Accelerated Opioid Detox off of fentanyl.
Both the patient and the support person come to the office each day. A support person is required for driving, administering the comfort medications throughout the day, and watching over the patient. Getting off fentanyl can be tough, so we use a minimum of five comfort meds around the clock to address the various symptoms that come along with opioid withdrawal. On the last day of the detox when we have cleared the receptors of the opioids, a long-acting naltrexone implant is placed in the abdominal region that will slowly dissolve over a two-month period, eliminating the need for daily oral naltrexone and assuring no missed dosing. Our program further provides six months of case-management and two more naltrexone implants, spaced two months apart.
Oscar and his girlfriend were a good team and grateful his insurance covered this treatment rather than having to stay on an opioid medication for an indefinite period and then trying to figure out how to get off it.
It has been almost four months since Oscar completed his detox, and we will see him soon for his 3rd naltrexone implant. It has worked so well for him, he will switch to a long-acting injectable form of naltrexone (Vivitrol) available closer to his home. It is rare for any patient not to appreciate my wonderful caring colleagues, but Oscar paid us the ultimate compliment: since his first visit here, he has referred two more people who have also successfully been able to detox off fentanyl and resume their normal life.
If you or a loved one are looking for an alternative to illicit (or licit) opioids that do not cause physical dependency such as Suboxone or methadone, please give us a call. We are happy to answer all questions.
Take care,
Joan Shepherd, FNP
*Name and (just a very few) details changed to protect this patient’s privacy.
