I was surprised earlier this week when Bridget Walsh, our Clinical Case Manager and I screened a former patient who wanted to return to Coleman Addiction Medicine for a second detox off opioids.
Why to Detox Again
People relapse for a variety of reasons. Screening someone who has already completed an Accelerated Opioid Detox and relapsed is important for us so we can figure out the next best plan to help this person achieve long-term sobriety. A second detox off opioids (such as Percocet, Roxicet, Opana, Oxycontin, oxycodone, Lortabs, hydrocodone, tramadol, fentanyl, morphine products, heroin, methadone, etc) is not unheard of. Sometimes it’s a surgery-planned or otherwise, sometimes it’s caused by an emotional situation, —that puts them back on pain medication; sometimes it’s being in the wrong place at the wrong time and not having the coping skills to deal with the situation.
Bill fell into the last category.
Trying Once More
He came to us for a detox off street heroin that turned out to be mostly fentanyl. Prior to using heroin, Bill had become physically addicted to pain medication. His pain management doctor was prescribing some of the medication; Bill was supplementing the meds with pills he purchased on the street.
Bill heard about our five-day program to help detox off short acting opioids in an outpatient setting. This worked well for him and he only missed a minimal amount of time from work. His support person and girlfriend of several years, was available to be with him for the duration. At the end of his detox, Bill got the naltrexone implant which effectively blocks the opioid receptors for about eight weeks. Bill was grateful and relieved. He was looking forward to returning to a life not driven by chasing dope.
The Stress of The Past Effects Future Recovery
When he was due to return to Coleman Addiction Medicine for a follow up naltrexone implant two months later, he didn’t make it. He absolutely knew he never wanted to touch another opioid again, and he felt very firm in his conviction. Life was busy, he was feeling great.
Things were going along nicely when one day Bill ran into a guy who had sold him drugs in the past. He purchased a few pills, telling himself he had this under control. Turns out, he didn’t. Bill’s brain responded automatically, recalling the euphoria it had experienced when heroin and fentanyl flooded his brain with dopamine.
The Dangers of Old Habits
Although I am condensing his journey into a few sentences, Bills’s next few months were spent lying to himself and his loved ones, getting high, spending lots of money, and falling into despair. He found a clinic that offered Suboxone and signed up. For several weeks he was keeping his cravings at bay by taking his daily dose of Suboxone. He soon realized he could trade a dose of Suboxone for other drugs to get high. When he gave a urine tainted with fentanyl at the clinic, he was discharged from the practice and called us.
What surprised me after talking to Bill and hearing about his experiences since we’d last seen him, was that he really didn’t understand the difference between using Suboxone vs. Naltrexone for his opioid use disorder.
The differences are important to understand.
Important Differences Between Suboxone and Naltrexone
1. Suboxone and other buprenorphine products create physical dependence, naltrexone does not
When a person takes buprenorphine for a period of time, they will become physically dependent on it (even in quite low doses) and will experience withdrawal symptoms if they stop it. Suboxone is a partial agonist and a partial antagonist, containing both buprenorphine and naloxone. This means buprenorphine produces effects such as euphoria or respiratory depression at low to moderate doses, but these effects are weaker than full opioid agonists such as methadone or heroin. This does not make Suboxone the wrong choice. When taken as intended, buprenorphine is very safe and effective. It can help dampen the effects of physical dependency to short acting opioids, such as withdrawal symptoms and cravings. Buprenorphine can increase safety in cases of overdose.
Naltrexone occupies the opioid receptors, preventing other opioids from having a place to ‘land’. Because naltrexone is a pure blocking agent, it does not create physical dependence or build up a tolerance to the drug. People who chose naltrexone therapy must be made aware that their body is also losing its tolerance to opioids during this period of abstinence. A person who relapses after having detoxed and not having used opioids for a long time is at a higher risk of having a fatal overdose. Accordingly, different forms of Medication Assisted Treatment (MAT) may be appropriate for different people.
2. Suboxone (and other opioids) must be completely out of your system before starting on naltrexone therapy
Many people with an Opioid Use Disorder (OUD) experience precipitated withdrawal. Both buprenorphine and naltrexone, if given too close to a person’s last dose of short acting opioids, can cause precipitated withdrawal. This happens when a person takes a substance that pushes opioids off the receptors abruptly.
The reason many people chose naltrexone over Suboxone is that they don’t want to be dependent on another opioid; Trading one for the other. While we support the use of Suboxone for the right patient, our program is one of the few in the country that has the experience in getting people safely and comfortably onto naltrexone.We do this over a three to eight day period, depending on the substances being eliminated and the co-morbidities of the patient.
We carefully ‘bump’ the existing opioids off the receptors as we slowly transition to naltrexone.
3. Suboxone is a controlled substance, naltrexone is not
People who chose to use Suboxone or other buprenorphine products (such as Bunavail, Zubsolv and Cassipa) to treat their opioid use disorder must find a provider who has a special DEA waiver, allowing them to prescribe it. This medication is highly controlled and patients receiving it must comply with strict state and federal guidelines, as well as restrictions and protocols required by specific programs. Patients taking Suboxone must comply with random pill/film counts, regular and random urine drug testing, and should be aware of the consequences of losing requesting early refills of these medications. Most programs require weekly to bi-weekly appointments. Buprenorphine products are not supposed to be prescribed to people who are also taking benzodiazepines such as Ativan (lorazepam), Valium (diazepam), Xanax (alprazolam), or Klonopin (clonazepam)—just to name a few. These measures are in place to help and protect both the patient and the provider, but it also adds a layer of complexity to using Suboxone to treat an addiction to opioids.
Naltrexone, being a pure blocking agent, does not require a special DEA license. Any doctor with a valid license is allowed to prescribe this medication. There is no extra scrutiny at the pharmacy, and a prescription for naltrexone does not show up on a state’s Prescription Monitoring Program. Coleman Addiction Medicine has specialized in using naltrexone therapy for over 25 years. We often use long-acting naltrexone in the form of a small tablet placed under the skin in the abdominal area. This will offer treatment to the opioid receptors for about eight weeks. Another long-acting form of naltrexone is a monthly injection called Vivitrol, which many insurance companies are covering now.
How Coleman Addiction Medicine Can Help with Opioid Use Disorder
Making the decision to stop using opioids requires some knowledge of what each of the choices for Medication Assisted Treatment (MAT) entails. Research shows that MAT is crucial in increasing the odds of long-term success for a person with Opioid Use Disorder. If you are seeking help for yourself or a loved one, please give our Care Advocates a call at 877-773-3869. They can direct you to one of our experts to help you with your choices; it can be daunting and confusing, especially when the stakes are so high.
Joan Shepherd, FNP