I had the great pleasure of seeing Jane last week at the Richmond office of the Coleman Institute for Addiction Medicine. Jane detoxed off Suboxone® two months ago through our accelerated outpatient detox process. With long-acting opioids, such as methadone and buprenorphine, the outpatient withdrawal management process is 8 days. Detoxing off short-acting opioids and opiates such as Percocet®, Roxicet®, and other oxycodone variations; Vicodin®, Vicoprofen®, and the other hydrocodone variations; hydromorphone aka Dilaudid®, heroin, and fentanyl generally takes 3-5 days, depending on a few different factors. Jane lives about two hours outside of Richmond and had traveled with her mom and her dog to get her second of at least three naltrexone implants as part of her early stage treatment process. Her story in brief: Jane smoked pot and drank in high school. It wasn’t until after high school she started to use pills from time to time. At some point, she had the horrible realization that she had developed a physical dependency on the pills. She was so ashamed, she didn’t tell her parents why she was dropping out of college. She got a job in the service industry and went on to have a very expensive pill habit. Skipping lots of details here…she moved to Florida where she had a friend in recovery and went through an agonizing cold turkey detox. She stayed abstinent from opiates for six years without being on any Medication-Assisted Treatment (MAT). Then she started dating a guy in recovery who relapsed. After impulsively taking "just one" 10mg oxycodone from this guy’s stash, she was full blown using again after just one week. She didn’t let this go on for long before she moved back home with her parents, found a reputable clinic, and went onto Suboxone® (buprenorphine/naloxone). Buprenorphine, methadone and naltrexone are the 3 evidence-based approaches of Medication-Assisted Treatment (MAT) for opioid use disorder.   SCHEDULE A CALLBACK   Owing to the high risk of relapse in opioid-dependent individuals, the most commonly prescribed treatment is maintenance treatment in which opioids with longer absorption times and half-lives are prescribed, such as methadone or the partial agonist buprenorphine, such as found in Suboxone® and other products. Jane had been taking Suboxone® 8mg/2mgday for two years and weaned to 2mg/0.5 daily when she came to our office for help with a detox. (Many people don’t know that stopping Suboxone® abruptly can precipitate severe withdrawal). I asked about her choice to go on Suboxone® when she returned to live with her parents in the town where she’d grown up. Even though Jane had been opiate-free for six years without the help of MAT, her relapse completely unnerved her. “I really thought I was no longer vulnerable”, she told me. “I had become complacent, I guess…but truthfully, I didn’t think I needed the support of recovery groups. I felt like I was doing a pretty good job staying clean by hanging out with good people, working, and being very physically active. I thought I was done with that phase of my life. Clearly, I wasn’t.” “Suboxone® was right for me at that time. I was able to get off the oxycodone pretty easily, although part of me was reluctant to start on Suboxone®. I have a friend who’s been on it for eleven years, and I don’t know if she’ll ever get off. I was just frightened not to be on anything. I was so freaked out that my relapse happened so quickly after so much clean time. The clinic required me to attend counseling sessions, and honestly, I found that to be incredibly helpful. I was in a good space to learn about coping skills that I had never been exposed to in the past by doing it on my own.” Although the buprenorphine was a good fit for Jane in many ways, she was quite anxious when she anticipated stopping; by then she’d heard horror stories from people who had tried to get off on their own. She discussed this extensively with the counselors and the addiction physician at the clinic and they told her about naltrexone. Naltrexone (our specialty at the Coleman Institute for Addiction Medicine for over twenty years) is a pure opioid antagonist – also called a blocker. It sits on the opioid receptors leaving no room for opioids to inhabit. And although it is available as a daily oral dose, compliance is obviously significantly better if taken in an extended release formulation such as a slowly dissolving implant or a monthly Vivitrol® injection. And studies have shown that the extended-release naltrexone is just as effective as buprenorphine in maintaining abstinence from opioids. Tanum, L, Solli, K. Latif, Z., Benth, J., Opheim, A., Sharma-Haase, K, (…) & Kunoe, N (2017). Effectiveness of Injectable Extended-Release Naltrexone vs Daily Buprenorphine-Naloxone for Opioid Dependence. JAMA Psychiatry.doi:10.1001/jamapsychiatry.2017.3206 “Naltrexone sounded like a great way to transition from Suboxone® to ultimate abstinence. I liked the fact that it was a pure blocker, and didn’t create either physical dependence or tolerance.” “When I told my counselors I was interested in going forward with this, there was a bit of an issue. They told me I would have to have the Suboxone® completely out of my system before I started the naltrexone. I was weaned from 8mg to 2mg/day over the course of several months, which was not easy, but I was motivated. But when it came time to drop down below 2mg a day, I just couldn’t tolerate it.” “I was working at a day-care center at the time, and I was so irritable. I wasn’t sleeping, my bowels were a mess, and my anxiety was through the roof. I googled around looking for solutions and that’s when I heard about the Coleman Institute.” The transition to naltrexone has been mostly positive, but Jane acknowledges that her energy levels were low immediately following the detox. She is grateful that her dog, Hugo, requires multiple walks. “He forces me to move,” she says, “otherwise I might turn into a total couch potato when I’m not at work.” “But in the big picture, life is good,” she said. “I am enrolled at a community college in the dental hygiene assistant program starting this fall. Even though I’m not getting Suboxone® from my old clinic, they are all completely supportive of what I’m doing, and I’m still going to group meetings weekly. As you can glean from Jane’s story, there are pros and cons to using the various Medication-Assisted Treatments to treat opioid use disorder, and every patient who comes through our doors has a unique situation that needs to be evaluated carefully. If you or a loved one is contemplating MAT and would like to discuss the options, please give us a call. Joan R. Shepherd, FNP   SCHEDULE A CALLBACK   Learn more about our accelerated opioid detox process from Dr. Peter Coleman.