As the world stopped to wonder in the months leading up and into early 2020, the opioid crisis in America continued on in silence. Even though the total number of opioid prescriptions written per year declined by nearly 40% since 2012, (1) the annual number of drug overdose deaths in the United States continued to rise. Tragically, by May of 2020, this number hit an all-time high of over 81,000. (2) The primary driver of this increase was illicitly manufactured fentanyl (nearly 100 times stronger than morphine). In 2019, the annual number of opioid overdose deaths was projected to increase (at least) through 2025. (3) Now in the aftermath of 2020 and beyond, increased social isolationism, joblessness, and strained mental health seem likely to only worsen the problem.

The American Society of Addiction Medicine (ASAM) defines addiction as a primary, chronic and relapsing brain disease characterized by an individual pathologically pursuing reward and/or relief by substance use and other behaviors. The Diagnostic Statistical Manual of Mental Disorders (DMS-V) defines opioid use disorder (OUD) as follows:

  • Opioids are often taken in larger amounts or over a longer period of time than intended.
  • There is a persistent desire or unsuccessful effort to cut down or control opioid use.
  • Craving, or a strong desire to use opioids.
  • great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  • Recurrent opioid use resulting in failure to fulfill major role obligations at work, school, or home.
  • Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  • Important social, occupational, or recreational activities of given up or reduced because of opioid use.
  • Recurrent opioid use in situations in which it is physically hazardous.
  • Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids.

Qualification of just two or three of the above symptoms would be considered a mild OUD. Four or five symptoms would define a moderate OUD. Six or more symptoms would be a severe OUD. Using these criteria, a 2014 study (4) found a lifetime prevalence of “any” prescription OUD in patients receiving chronic opioid therapy for noncancer pain to be 41.3%. This is important to realize, since four in five new heroin users started out misusing prescription painkillers. (5)

If you or a loved one is suffering from opioid addiction, know that you are not alone and that recovery is possible! In 2018, an estimated 2 million people had an OUD. (6) There is no clinical screening tool that can perfectly predict who will ultimately develop an OUD. (7) It can affect anyone – old or young, rich or poor. There should be no shame in the struggle against opioids – only in not getting help. When it comes to treating OUD, there are two general approaches: abstinence-based treatment (ABT) and medication-assisted treatment (MAT). Both approaches may incorporate counseling and/or support groups (i.e., Narcotics Anonymous).

Abstinence-Based Treatment

Until recently, detoxification and counseling alone composed the standard of care for opioid addiction. While good-intentioned, this approach may have underestimated the effects of addiction on the brain and the time needed to heal. Cravings and symptoms of withdrawal are the result of significant changes in neural pathways, neurotransmitter and receptor concentrations, and overall brain function. (8) Structural brain changes may also develop. Reduced size of the prefrontal cortex has been described. (9) While counseling has an important role to play, addiction is not something that can be simply willed away. A 2010 study (10) found that of 109 patients who were admitted to a residential addiction treatment service for detoxification, 91% relapsed within two years and 59% within the first week. A 2016 study (11) reported relapse rates after opioid detoxification ranged from 32-70% after six months and 72-88% after 12-36 months, despite multidisciplinary efforts. This is particularly concerning, since renewed use after abstaining for a time is associated with a high risk of overdose (and death). Surely, there must be a better way.

Medication-Assisted Treatment

Perhaps most often when people think about the treatment of heroin addiction, they think of methadone. In fact, the Controlled Substances Act of 1970 and the Narcotic Addict Treatment Act of 1974 allowed for the first time the dispensation of methadone in federally waived clinics for the purpose of treating opioid addiction. Early studies demonstrated that methadone was an effective treatment for opioid addiction, in that it reduced criminal behavior and improved function. (12,13) Several studies later confirmed that indeed, methadone maintained better treatment retention and reduced heroin use more so than abstinence-based therapy. (14) However, methadone is not a benign medication. It is a full opioid receptor agonist and so there is potential for abuse and overdose if not taken as prescribed. Methadone also has the unique ability to affect cardiac rhythms, even potentially leading to cardiac arrest. Therefore, when used for the treatment of patients with opioid addiction, a significant amount of oversight and regulation is required (as defined by law). Typically, patients need to attend a methadone clinic on a daily basis and be supervised as they take their medication. While this can be an effective treatment, it is not a practical option for those who work, travel, or have other interfering obligations.

Buprenorphine was first developed in the 1970s as a safer opioid than morphine for the treatment of pain. (15) It was later realized that this medication could be a superior alternative to methadone for the purposes of treating opioid addiction. After several confirmatory studies, the addiction treatment community (and the drug’s manufacturer) lobbied for an exception to the Narcotic Addict Treatment Act of 1974, and so, the Drug Addiction Treatment Act of 2000 was born. This allowed specially trained and authorized physicians to prescribe buprenorphine specifically for the purposes of treating addiction. In October of 2002, the Food and Drug Administration (FDA) approved buprenorphine and a combined formulation of buprenorphine and naloxone for the treatment of opioid addiction. Many brands and forms of buprenorphine now exist, including Suboxone (FDA approved, 2002), Zubsolv (FDA approved, 2013), Bunavail (FDA approved, 2014), and Sublocade (FDA approved, 2017). They come in sublingual/transmucosal dissolvable tablets and films, and once-monthly injections. Generic formulations are also available.

Why is buprenorphine special?

Buprenorphine is a long-acting, high-affinity, partial opioid receptor agonist. The terminal half life of sublingual buprenorphine ranges from 28 to 37 hours. (16) The terminal half life of subcutaneously injected buprenorphine (Sublocade) ranges from 43 to 60 days. (17) This long half life prevents the many highs and lows associated with opioid addiction. The opioid receptors are stabilized. Cravings are managed and withdrawals are avoided. Buprenorphine also binds to the opioid receptor with greater strength, that is, higher affinity, than nearly every other opioid, including hydrocodone, morphine, and heroin. (18) When buprenorphine is acting on the opioid receptor, other opioids are blocked from inducing an effect, thus minimizing relapse potential. Buprenorphine is also unique in that it is a partial (versus a full) opioid receptor agonist. Whereas morphine (or heroin, for example) may result in full 100% intrinsic activity of the opioid receptor, buprenorphine may only yield a partial 67% receptor response. (19) For opioid-dependent individuals, this implies a ‘ceiling-effect’ that limits abuse potential and risk of overdose. Keep in mind, this ‘ceiling-effect’ does not apply to opioid-naive individuals, and so the same high risks of any opioid must still be considered! In summary, these unique pharmacologic properties allow for the safe and effective treatment of opioid addiction in the office setting.

What does treatment look like?

Step 1: Induction

After a thorough history, physical exam, and urine drug screen, your physician may decide to start you on buprenorphine for the treatment of an opioid addiction. It is important to have all other opioids totally out of your system before starting buprenorphine. This is ensured by waiting 12-24 hours after last opioid use and by allowing for the development of mild withdrawal symptoms, as defined by the Clinical Opiate Withdrawal Scale (COWS). Signs of mild opioid withdrawal may include restlessness, runny nose, yawning, or abdominal cramping. As opioid withdrawal progresses, increased heart rate, sweating, abdominal cramps, and/or bone pain may develop. Starting buprenorphine at the onset of mild symptoms of withdrawal prevents a precipitated or severe withdrawal from developing.

Remove any stumbling blocks. Discard any leftover opioid pills and/or substances that may still be in your possession. Delete phone numbers and contacts of suppliers, dealers, or other people that do not have your best interest at heart. Build a ring of protection around you. Create accountability. While certain friends or family members may provide that support, sometimes they can simply be well-meaning. Speaking to a certified psychotherapist or sharing in a vetted support group comes highly recommended.

Step 2: Stabilization

Few dose adjustments may be necessary, especially in the early stages of buprenorphine therapy. After your initial visit, close follow-up is required. Signs that your dose may be too high include sleepiness and general fatigue. Your dose may be too low if you are experiencing ongoing symptoms of withdrawal, cravings, or relapse. You must alert your physician if you are experiencing any of these symptoms. Do not adjust your dose of buprenorphine without prior authorization. This period of stabilization may last 2-4 weeks.

Step 3: Maintenance 

Once stabilized, a motivated and compliant patient will follow-up once a month in clinic for follow-up evaluations, random urine drug screens to ensure treatment success, and medication refills. The duration of treatment will vary from patient to patient. Factors that influence the duration of treatment may include the severity and chronicity of the opioid addiction itself, any history of relapse or overdose, the presence or absence of a meaningful support network, and whether or not steady progress is being made toward recovery. Generally speaking, the longer someone remains in treatment, the better chance they have at making a meaningful recovery. (20-23)

Is it possible to come off this medication and remain free from opioid addiction? Of course! It just takes time for your brain to heal, the receptors to reset, new pathways to be formed, and your life around you to be rebuilt, relationships repaired, and new purpose to be discovered. To achieve this, at a minimum, 6 months of treatment is recommended. On average, duration of treatment will last 1-2 years. For a few, it can be lifelong. 

Some may ask, aren’t you just switching one drug for another? Whereas illicit opioid use will invariably conclude in catastrophe – physical illness, mental illness, loss of family, friends, income, even life itself – MAT clearly delivers statistically significant and clinically apparent results. Unfortunately, only 11% of those with opioid addiction ever get treatment. (24) Don’t let that be you. A better life awaits.

 

Give us a call today: (469) 290-7246

 

References:

  1. CDC. U.S. Opioid Dispensing Rate Maps. Center for Disease Control and Prevention website. https://www.cdc.gov/drugoverdose/rxrate-maps/index.html. November 10, 2021 Accessed August 3, 2022.
  2. CDC. Overdose Deaths Accelerating During COVID-19. Center for Disease Control and Prevention website. https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html. December 18, 2020 Accessed August 3, 2022.
  3. Chen, Q., et al. Prevention of Prescription Opioid Misuse and Projected Overdose Deaths in the United States. JAMA Netw Open. 2019;2(2):e187621.
  4. Boscarina, J.A., Hoffman, S.N., and Han, J.J. Opioid-use disorder among patients on long-term opioid therapy: impact of final DSM-5 diagnostic criteria on prevalence and correlates. Subst Abuse Rehabil. 2015; 6:83-91.
  5. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United Sates: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.
  6. SAMHSA. Medication-Assisted Treatment. Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/medication-assisted-treatment. July 25, 202 Accessed August 3, 2022.
  7. Ducharme J, Moore S. Opioid Use Disorder Assessment Tools and Drug Screening. Mo Med. 2019;116(4):318-324.
  8. Kosten, TR and George, TP. The Neurobiology of Opioid Dependence: Implications for Treatment. Research Reviews-The Neurobiology of Opioid Dependence
  9. Liu, X., Matochik, J., Cadet, JL. et al.Smaller Volume of Prefrontal Lobe in Polysubstance Abusers: A Magnetic Resonance Imaging Study. Neuropsychopharmacol 18, 243–252 (1998).
  10. Smyth BP et al. Lapse and relapse following inpatient treatment of opiate dependence. Ir Med J. 2010 Jun;103(6):176-9.
  11. Chalana H, Kundal T, Gupta V, Malhari AS. Predictors of Relapse after Inpatient Opioid Detoxification during 1-Year Follow-Up. J Addict. 2016;2016:7620860.
  12. Dole VP, Nyswander M. A medical treatment for diacetylmorphine (heroin) addiciton. A clinical trial with methadone hydrochloride. JAMA. 1965 Aug 23;193:646-650.
  13. Dole VP. Methadone maintenance treatment for 25,000 heroin addicts. JAMA. 1971 Feb 15;215(7):1131-1134.
  14. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2003;(2):CD002209. doi: 10.1002/14651858.CD002209. Update in: Cochrane Database Syst Rev. 2009;(3):CD002209. PMID: 12804430.
  15. Velander, Jennifer. Suboxone: Rationale, Science, Misconceptions. Ochsner Journal 18:23-29, 2018
  16. Welsh C, Valadez-Meltzer A. Buprenorphine: a (relatively) new treatment for opioid dependence. Psychiatry (Edgmont). 2005 Dec;2(12):29-39. PMID: 21124750; PMCID: PMC2994593.
  17. Subclocade [package insert]. Chesterfield, VA: Indivior Inc.; 2017.
  18. Gudin, J., Fudin, J. A Narrative Pharmacological Review of Buprenorphine: A Unique Opioid for the Treatment of Chronic Pain. Pain Ther 9, 41–54 (2020).
  19. Yassen A, Olofsen E, van Dorp E, et al. Mechanism-based pharmacokinetic-pharmacodynamic modelling of the reversal of buprenorphine-induced respiratory depression by naloxone : a study in healthy volunteers. Clin Pharmacokinet. 2007. 46(11):965-80.
  20. Weiss RD et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011 Dec,68(12):1238-1246.
  21. Kakko J et al. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised , placebo-controlled trial. Lancet. 2003 Feb 22;361(9358):662-668.
  22. Parran TV, et al. Long-term outcomes of office-based buprenorphine/naloxone maintenance therapy. Drug Alcohol Depend. 2010 Jan 1;106(1):56-60.
  23. Hser YI, Evans E, Huang D, Weiss R, Saxon A, Carroll KM, Woody G, Liu D, Wakim P, Matthews AG, Hatch-Maillette M, Jelstrom E, Wiest K, McLaughlin P, Ling W. Long-term outcomes after randomization to buprenorphine/naloxone versus methadone in a multi-site trial. Addiction. 2016 Apr;111(4):695-705. doi: 10.1111/add.13238. Epub 2016 Jan 13. PMID: 26599131; PMCID: PMC4801718.
  24. NIDA. Making Addiction Treatment More Realistic and Pragmatic: The Perfect Should Not be the Enemy of the Good. National Institute on Drug Abuse website. https://nida.nih.gov/about-nida/noras-blog/2022/01/making-addiction-treatment-more-realistic-pragmatic-perfect-should-not-be-enemy-good. January 4, 2022 Accessed August 3, 2022.

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