We had an incredibly busy season at the Coleman Institute for Addiction Medicine. We were challenged to keep staff and patients safe from COVID-19, navigate holiday schedules, and respond as best we can to the tsunami wave of people desperate for help from various addictive substances. If holidays and COVID-19 weren’t enough to add to people’s vulnerability to using opioids, benzos, and alcohol, the relative ease of finding these drugs has made a bad problem much, much worse.
Our patients come from all walks of life. People with Alcohol Use Disorder may be high functioning executives or barely out of their teens, just at the age where they should be opening doors to becoming who they are meant to be.
Our patients suffering from addiction to benzodiazepines such as Xanax®, Valium®, Ativan®, etc., come from around the world (literally), and upwards of 75% of these patients are taking their medication exactly as prescribed by their health care providers.
What If I Am Using Both Benzos and Opioids?
The highest number of patients we treat come to us for help getting off opioids such as street drugs like heroin, kratom, and fentanyl, or prescribed pain medication, such as Percocet, Dilaudid, Vicodin, Hydrocodone, Tramadol, and similar drugs.
The Coleman Institute for Addiction Medicine has Accelerated Detox Programs to address three major types of these Substance Use Disorders (SUD). There is nothing quite as humbling and gratifying as working with these courageous, motivated individuals and watching them emerge from the prisons created by addiction. But…for a person with a SUD to achieve remission, he or she simply must give their brain a chance to heal. A brain which has developed a physical dependence or tolerance to a substance is a vulnerable brain.
Although our detox programs are safe and efficient, physically getting off the substance is only the first step. What a patient does after his or her detox is vitally important, and our entire staff is invested in helping our patients achieve long term success. With that in mind, here are five of the scariest things I’ve heard from my patients:
1. I can’t get treatment; my job would fire me if they found out.
Please do not let this stop you from seeking treatment! Our patients’ confidentiality is heavily guarded and respected; it’s the law. Patients who are being treated for substance use issues are protected not only by HIPAA, but also more layers of stringent privacy and security regulations including 42 CFR Part 2.
Because our opioid and benzodiazepine detox programs are accelerated, (that is, we safely get patients off substances in 3-10 days in an outpatient setting), most patients are able to take a few days off from work and return within 48 hours after completion. Many patients use vacation or other PTO options.
2. I use cocaine, but it’s no big deal, I only use it occasionally.
I know many of my young patients could teach most med students about street drugs, so it is not news to them that a high percentage of non-prescription drugs contain fentanyl. Fentanyl is a synthetic opioid 50-100 times stronger than morphine. So if someone is ‘just an occasional cocaine user’ or ‘only buys benzos when detoxing from heroin’, he/she is at great risk these days of overdosing because fentanyl is being combined more and more with other street drugs. It takes only a very small amount of fentanyl to be deadly.
UNDERSTANDING ACCELERATED OPIOID DETOX
3. My partner is still using, but I’m not worried because I have the implant.
I have seen this time and again in my career as a medical provider in addiction medicine. Patients get through our detox, get their long-acting naltrexone implant, and then, rather than focus on figuring out how to avoid ‘people, places, and things’ associated with their previous life of drug use, some of our patients have a misplaced loyalty to old friends or family who are still using. They figure since they have the implant, it is ‘safe’ for them to be around these situations. Rather than creating their own safe world, they continue to stay in ‘enemy-territory’ with a small shield: their naltrexone implant.
And although the naltrexone is a pure opioid blocker and as long as it is sitting on the opioid receptor, it will prevent an opioid from landing there, it can eventually be pushed off. The patient who continues to frequent the same activities while he/she is sober, is not creating new habits, new neural pathways for his/her brain, not taking the most advantage of having the implant. A naltrexone implant provides time to begin to rebuild a life the way you want it to look in the future.
4. I don’t need the naltrexone implant…I never intend to use opioids again!
Successful sobriety numbers are tragically low for people with Opioid Use Disorder who don’t use some kind of Medication Assisted Treatment (MAT). At the Coleman Institute, we nudge the opioids off the opiate receptors and replace them with naltrexone, a pure blocker which is not addictive. People who choose our clinic for an Accelerated Opioid Detox are essentially agreeing to utilize a long-acting form of naltrexone.
Until the brain heals and a person has developed skills for and acquired a strong support system to stay sober, the chances of success are greatly diminished. We never judge a patient harshly who has relapsed and returns for another detox; but we look closely with them to see how to change the outcome this time around. Usually that means adding in another layer of intensive counseling coupled with a strong commitment to continuing naltrexone therapy.
For other people, an Accelerated Opioid Detox is not the best fit, and they find that using buprenorphine products or methadone make most sense for them. Both of these MAT choices can help a person get steady in their long term recovery journey.
5. I should be ok, I’m taking it just as the doctor prescribed.
Although people have become more knowledgeable about drugs that can create physical dependence if used over time, I still meet patients regularly who are shocked to learn that they have developed a physical tolerance to a medication, even though they have never misused or abused it; in fact, they are taking it exactly as their doctor prescribed. This can happen with pain medication and benzodiazepines.
Many of the patients who come to the Coleman Institute were prescribed medications such as Ativan (lorazepam), Xanax (alprazolam), or Valium (diazepam) — and there are several more—to treat conditions such as anxiety or insomnia. These medications are meant to be used short term, at best. Here’s a scale often used to assess the severity.
These patients are horrified to realize that they simply cannot stop using these medications without multiple side effects. People can slowly and safely cut down their benzodiazepine use under their doctor’s supervision, but it can be extremely difficult and take a very long time.
The Coleman Institute uses tiny doses of flumazenil to slowly remove the benzos from the brain and allow the healing process to begin. Importantly, medication must be used to help prevent seizures, and address possible issues such as anxiety and insomnia.
Successful Recovery is Possible
As I stated earlier, I can’t imagine working with a more motivated and interesting group of patients. We get their challenges and we rejoice at their successes.
As 2021 unfolds, everyone will be subject to their own personal issues. Do you need help to safely and efficiently stop taking some kind of addictive drug or medication? A wise Chinese proverb states “The best time to plant a tree was 20 years ago, the second best time is now.”
Joan Shepherd, FNP
