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In my previous article, I reviewed many aspects of addiction, including structural and functional changes in the brain with their accompanying symptoms. This article focuses on the bright hope that medication treatment has to offer, while the next article will focus on the other critical aspects of treatment and care for persons addicted to opioids. You might be very surprised to learn of the amazing results from applying these treatments!
There are 4 basic treatment options in which medications are used:
- Withdrawal Management (formerly called Detoxification)
My training and expertise is in the field of Buprenorphine use, but I will make comments about the other options.
Withdrawal Management (Detoxification)
This involves the rapid discontinuation of opioids or heroin over a few days or weeks. Control or reduction of the withdrawal symptoms is facilitated through medications. Clonidine is used for the adrenergic symptoms, which is part of the epinephrine-induced fight or flight response to stress. A sleeping pill is added to try to help sleep, and an anti-nausea pill.
At the end of withdrawal management, patients are still left with strong cravings for the opioid. If they end up in jail, they will ‘detoxify’ or go through withdrawal without any medication support. This is extremely difficult, as you would imagine.
After treatment with this approach, 50% are still abstinent at 6 months, but at 12 months less than 15% are still abstinent.
There is a high risk of opioid overdose with this approach. Because patients are opioid/heroin free for months, their tolerance has reduced. This means a much smaller dose will get the same effect as the larger dose previously. They may inadvertently take the larger dose of months ago, which may cause respiratory depression (stop breathing) and death.
Mu-Opioid Receptor Stimulants (Agonists)
Methadone and buprenorphine both fit into this category. They stimulate the u-opioid receptors, the same receptors that are stimulated by heroin or opioids. This puts them in the same category as opioids but with some substantial differences:
- They do not cause the structural and functional changes in the brain that other opioids do
- Tolerance does not build up, so the dose remains the same over time.
- There are no withdrawals once a stable dose has been found, and the cravings go away.
- Without cravings and withdrawal the compulsive drive to ‘use’ is gone.
- Because the mu-opioid receptors are filled with these medications, if patients did ‘use,’ there would be no euphoria (or pain relief) like before.
- They do have the same side effects as other opioids, including respiratory depression, sedation and constipation.
With these medications as treatment, studies have shown consistent reductions in opioid-related dysfunctions, including:
- death rate
- IV drug use
- crime days
- HIV seroconversion
- relapse to IV drug use
Since withdrawal symptoms are totally eliminated, patients have improved abilities to :
- become and stay employed
- become healthy
- maintain social relationships—family, friends, co-workers.
Methadone has been around since the 1960s and is considered a “full” opioid agonist, stimulating the mu-opioid receptors fully as do other addictive opioids. Typically the daily dose is administered daily at the clinic. It does have a side effect of affecting electrical conduction in the heart (found on EKG in the QTc interval). The ability to write prescriptions does not require special training.
Buprenorphine was introduced in October of 2002 and is considered a “partial” opioid agonist, stimulating the mu-opioid receptors about ½ as much as other addictive opioids. Typically, patients are seen at least monthly in the clinic where they are given a prescription for one month. There are fewer side effects with this medication, including death rate. In fact, there are no deaths related to buprenorphine alone; only in combination with other medications that have respiratory depression as one of their side effects. Practitioners who prescribe buprenorphine must be ‘waivered’ to prescribe, which includes taking a course and passing a written exam.
Mu-Opioid Receptor Blocker (Antagonists)
Naltrexone is a mu-opioid receptor blocker, so is not considered an opioid. It does not help with withdrawal symptoms or cravings, and must be administered when the patient is not on any opioid or heroin (after withdrawals). It was approved in 2010 with both daily oral use and monthly intramuscular use. As with the agonists, there is no response to opioid/heroin when the receptors are blocked with Naltrexone.
Dr. Gardner’s Clinical Experience
The treatment of persons with addiction has been a most satisfying practice. Since I took over an already established practice, the majority of patients who I treat had started and were stabilized before my practice started. They are all functioning in society, holding jobs and working on building family relationships.
Most of the people who became new patients of mine have continued along the same path. In the first few months, habits and friends are hard to break and relapses have occurred, but this does not persist. A few people were ‘brought in’ by parents, were probably not heavily motivated and dropped out of the treatment program early.
The Pharmacology of addiction recovery is only a part of a long-term recovery process.
My next article will address the critical needs of therapy and counseling. The necessary skill sets for success will be reviewed, along with the importance of social networking and connections with others.
Stan Gardner, M.D., CNS, is board certified in Anti-Aging and Regenerative Medicine. He works out of Keys to Healing Medical Center in functional medicine for all ages, (801) 302-5397. He also works in addiction recovery out of Rising Health, (801) 419-0705.