TREATMENT FOR ADDICTION TO OPIOID PAIN MEDICATION
More than 12 million people reported using opioid pain medication for non-medicinal reasons in 2010. The most common question people on prescription opioids ask themselves is, “How do I stop using my medication.” This question can have an array of answers. There is no “right” or “wrong” way to stop pain medication. Each individual that experiences the feeling of being trapped by a pill, a medicine, prescribed by a doctor, wants to know how to stop. How to stop opiates without being in pain or experiencing the pain that the pills at the moment, are keeping at bay. Pain- the one word that stops people in their tracks. The thought of being in pain is what keeps most recipients of prescription opioids from seeking help. The second word that holds this same person back is… rehab. Is rehab the only solution though? We will go through the many ways to get off prescription medication step by step, and also address the method we generally suggest which would be Suboxone for Medication Assisted Treatment.
COLD TURKEY METHOD FOR OPIOID DETOX
Cold turkey is a term meant to describe a person who stops using opioids on their own, at home or on a friend’s couch. A person will typically do this without the use of narcotics or other prescription medication. This method is often used if a person is not able to afford to take time off or go to medical detox. To start this process many will begin to take their medication in lower doses and increments. This is often called a “taper”, tapering off the pain pills. Tapering tends to be difficult for many given the nature of addiction and it can sometimes lead to increased use. After they have gotten as low on their medication as possible it’s ideal to take a week off from work. When you stop using opiates abruptly, your body will react, leading to symptoms of withdrawal. Some are not fortunate enough to take time off and will simply have to “white knuckle” through their daily routine. Prescription opioids can take much longer to fully detox off than heroin. Withdrawal symptoms can last between seven to thirty days. Typically, symptoms become less severe after the first week and the detoxing person’s conditions will keep improving. Once the body and brain start to react to the lack of opioids in the system. Physical onset symptoms will include sweating, eye-watering, muscle aches, excessive yawning, and chills. Most people experience cramping in the legs, an overall feeling of restlessness, sleeplessness and low energy. Preparation is essential if someone is attempting to detox on their own. There are many over the counter medicine’s that can combat these stage one symptoms. These medications include vitamins like B-12 which increases energy levels 5-HTP which help boost one’s mood and overall wellbeing. Anti-diarrheal medication since diarrhea is a side effect that affects almost everyone during the detoxification process. Ibuprofen or Tylenol for aches and pains, some people even recommend Tylenol PM or Melatonin for sleep. Do not take any medication for longer than recommended or doses higher than recommended. Dehydration is another symptom which is very common due to the combination of diarrhea and nausea. Stay hydrated!! Drink fluids like juice and Gatorade. Exercise is a very helpful implementation that will help rejuvenate a person’s mental and physical strength as well as help rejuvenate brain endorphins. If a person is interested in Chinese medicine some options that are alleged to help most are Tai-Kang-Ning, which is thought to be effective for moderate to severe heroin withdrawal, ginseng, and U’finer, which is a Chinese herbal blend believed to repair the damage opiates may do to the brain. If you are a diabetic or have any serious medical issues an at home detox is not recommended. It is not safe and any person doing an at home opioid detox should have a doctor on call always.
METHADONE MAINTENANCE PROGRAMS
Methadone maintenance is a form of self-detox that incorporates, of course, methadone hydrochloride. Methadone has a long history which began in Germany during World War II. A German pharmaceutical company created the synthesized drug ‘methadone’ in 1939. At first there were some reports, which may not have been completely accurate, that ceased broad use of the drug. Some of the side effects reported were nausea, overdose, rapid tolerance development, signs of toxicity and an appearance of illness. These reports did not stop the manufacturer however from marketing the drug as having “little risk for addiction”. After the war was over Germany’s patents and other assets would end up being distributed to allies. IG Farben was the pharmaceutical company responsible for synthesizing methadone’s developments. These developments were confiscated by the US Department of Commerce Intelligence and brought to the US. By 1947, the drug was approved as a painkiller here in America. It’s common knowledge that after WWII there was a surge in heroin usage. Between 1950 and 1961 there was a 28% increase in0 death by heroin, the average age of death was 29 years old. Coinciding with overdose there was a drastic spread in disease which prompted locals to come up with a solution. The Rockefeller Foundation came up with a program that would help clean up the streets of New York City, which is where over half the addicts in the country lived. Their program would be called a “Methadone Clinic”. Methadone is a long-acting opiate agonist. Its half-life can last twenty-four to sixty hours, unlike heroin which only has a two to four-hour half-life. This long-lasting quality of methadone, coupled with the distribution method, which is a daily dose in either liquid or wafer form, made methadone an attractive medication. One dose of methadone can get a person through an entire day, which makes it a great treatment method. The program had and has the potential to decrease the spread of disease and reduce crime while allowing a person to regain a stable lifestyle.
If a person is to use methadone maintenance to get off prescription pills there are a few details about the medication and its programs to be aware of. The more a potential patient knows, the more informed a decision they can make, on whether to go on maintenance or try another method. Methadone Maintenance programs are a first thought for many because it can be very cost efficient. Many programs use a sliding scale to assess one’s costs if there are any at all. Most clinics are funded through government subsidies. Besides the cost of treatment though, depending on personal situations, there could be downsides to this program. This program will be a part of a person’s daily routine and lifestyle. Most clinics open early and require participants to come in between 5 a.m. and 7a.m, every day. The daily in-person doses will continue for months or until the clinic deems a patient responsible enough to take home multiple days’ worth of methadone at a time. The responsibility to acquire “take homes” is typically determined by a patient’s commitment to coming in on time, not missing doses, attending weekly counseling and passing all required drug tests. If a person fails a drug test there will be consequences including not being able to take home any medication. After a certain amount of failed drug tests, a client can be refused service, and kicked out of the program. Methadone maintenance differs from other programs because they start clients off on a lower dose working dosages up daily and weekly. Many people who use methadone stay on the program for extended periods varying from a few months to a lifetime. When or if a patient is ready to come off methadone it is up to the clinic to decide whether they deem the patient ready and how fast or slow the taper will be. A normal practice is to put patients on a “blind dose”. This is when the patient is unaware of the amount of medicine that is being prescribed. This method is thought to help the prescribed patient handle being tapered down because the patient is unaware of what dosage he or she is taking, therefore they are less likely to psych themselves out. For all the patient knows they could be on a regular dose.
When a patient at the clinic decides they have stabilized their lives and ready to come off methadone, it can be a long process. There is a physical and mental detoxification that occurs from the discontinuation of methadone. Cleansing the body from methadone metabolites can take weeks because of the long half-life of the medication which this article touched on earlier. An ideal milligram to ween down to suggested by a medical standpoint is said to be between 60mg and 120mg. At this point a Doctor has the ability to help the patient through the detox. A participant in the methadone program is unable to use drugs such as buprenorphine or naloxone without having had completely rid their bodies of any traces of methadone first. This can take about seven to ten days. If a person takes one of these other prescription detox medications like buprenorphine, it will throw a person’s body into full withdrawal symptoms. These symptoms include but are not limited to: diarrhea, vomiting, exhaustion, sweating, chills and muscle aches. These side effects are similar to what a methadone detox feels like but taking naloxone or buprenorphine will intensify it. A detox from methadone will generally last from three to six weeks and post-acute withdrawal can last three to six months or longer.
BUPRENORPHINE AND NALOXONE MEDICATED DETOX
Buprenorphine was developed by UK-based Reckitt & Colman Products in 1978. That same year, a clinical study determined that buprenorphine could be helpful in reducing cravings of pure opioids in patients with an opioid abuse disorder. In 1982 another study was done that showed analgesic properties with a low potential for opiate abuse. Buprenorphine can be used to manage moderate to severe chronic pain. The drug was released to be used in the United Kingdom in 1978. In 1995 the medication was available in France and in 2002 the Federal Drug Administration approved buprenorphine for treatment of opioid dependence in the United States. Buprenorphine appears to have less potential for psychological and/or physical dependence than traditional full-agonist opioids like methadone. In 2011 the pharmaceutical companies discontinued dispensing of Suboxone (8mg buprenorphine/2mg Naloxone) tablets (which many remember as being an orange color and orange flavored pill) and replaced with a sublingual film. The film replacement was created to help curb the abuse and misuse of the tablets. The Suboxone film is tamper proof, meaning it cannot be melted down, injected or snorted with the new formula.
USING SUBOXONE MAINTENANCE TO TAPER OFF PRESCRIPTION MEDS
As with any detox method, there are always different risks, side effects, and benefits to be aware of before making a decision. Buprenorphine and the like come in many different forms. Suboxone is a sublingual film (dissolves under the tongue) which contains Buprenorphine and Naloxone also known as Naltrexone or Narcan. Narcan is the drug commonly used to revive a person that has overdosed on opioids. Subutex is a sublingual tablet that is comprised of only Buprenorphine, with generic versions available. Other less popular but available brand names are Zubslov, a sublingual tablet that comes in a menthol flavor. Bunavail buccal film is made from the two active ingredients Buprenorphine and Naloxone and adheres to the inside of the cheek instead of under the tongue. There are many choices when it comes to how a patient can have their medication prescribed. A doctor that is licensed to practice addiction medicine should be able to help each individual choose which variation is best for them. People often use Suboxone for a maintenance program or for a short-term detoxification process. Buprenorphine has become more popular for maintenance, treatment of opioid abuse and detox. Beyond being a safer alternative dependence wise to Methadone, it allows patients to bring home their medications and self-administer the medication. This self-administration alternative helps patients return to a “normal” lifestyle sooner than they would with the daily Methadone maintenance programs.
Taking this medication too soon after discontinuation of opiates can lead to precipitated withdrawal. Precipitated withdrawal is basically when a person takes Suboxone too soon and the body’s reaction is that of severe withdrawal symptoms. When a person still has full opioid agonist chemicals in their body like heroin or pain pills and proceed to take a partial agonist like Buprenorphine it can cause rapid onset withdrawal. Though one might not still feel the effects from their last dose of either prescription pain medication or heroin, it’s important to listen and consult a doctor that is familiar with half-lives of these medications and narcotic drugs. The first dose of a buprenorphine medication should be taken when moderate withdrawal symptoms are apparent. A person can rate their withdrawal severity using the clinical opiate withdrawal scale or “COWS” method. Many doctors will suggest taking a smaller dose at first, for safe measure. The switch from prescription pain medication to Buprenorphine does not take a long time. Some people report feeling fatigued or unable to sleep well but most of the side effects are mild and do not last very long. To avoid relapse on this medication, make sure to seek therapy if thoughts of using occur. If a relapse does occur, make sure to tell an addiction medicine doctor so a plan can be made to get back on the medication safely. There is no requirement to stay on this medication for an elongated period, more so a personalized treatment plan to meet each individual needs. For instance, if a person has severe chronic pain they may want to stay on this medication long term to prevent relapse on pain medication while also managing their pain in a safe effective manner.
When one is ready to begin to taper off Buprenorphine, the prescribing doctor should work with them to attain a common realistic goal. As with any drug taken daily if its use is stopped abruptly there will be withdrawal. Suboxone and Subutex both suppress detox symptoms from opiates but have physical detox symptoms of their own. These symptoms are very similar to other opiate withdrawals and include diarrhea, muscle aches, loss of appetite, insomnia, anxiety, restlessness, irritation, and fatigue. The lower of a dosage a person is on the less severe these symptoms will be. Unlike Methadone, Suboxone only partially activates the brain’s opiate receptors, greatly reducing withdrawal symptoms and cravings, while Naloxone prevents the euphoric and dangerous effects of taking opiates, minimizing the risk of abuse or overdose. This reason along with being able to get a prescription for monthly doses opposed to daily Methadone doses has made the popularity of this maintenance program grow over the years. As previously stated Methadone patients slowly increase the amount of medication they take over time, Suboxone recipients start at a higher dose and decrease their dose until they’re stabilized. The highest dose of Suboxone that can be prescribed is 32mg.
Cost of Treatment for Addiction to Opioid Pain Medication
A patient can get prescribed medicine weekly or monthly. There are no refills allowed on buprenorphine prescriptions because it is a controlled substance, though most pharmacies will allow a person to get partial fills weekly or even daily. Suboxone maintenance programs are not free, and most programs are not government funded, though there are some funds being distributed to help offset costs of doctor office visits. There are also programs to receive medication at a discounted or reduced rate. Some manufacturers offer coupons online as well. The government did increase the number of patients an addiction medicine doctor is able to treat in 2017 from 100 patients to 275 patients in the United States. This action was prompted by a spike in opioid dependence and overdose. Daily buprenorphine costs $4,000 to $5,000 per year and methadone costs $2,600 to $5,200 (Blueshift, 2017). Cost for the implant form of buprenorphine is $4,000 to $6,000 for six months. These estimates are based on an average dose of 16 mg/day, not including the $100-$200 fees for office visits. Office-visits are required monthly. Most insurance covers at least part of either an office visit or the prescription. Pricing depends on health care plan, pharmacy, and generic drug availabilities.
Opioid Addiction and Dependence Drug Detoxification
A medical detox facility, for most people, is the easier more convenient option to get off prescription opioids. Medical detoxes have only been available for a few decades now. Before actual medical detoxes were a practice many alcoholics and addicts would end up in sanitariums or psychiatric wards. Bellvue hospital which had an infamous “drunk ward”. In this “drunk ward” they offered to drug addicts and alcoholics what became known as the ‘belladonna treatment’. The treatment required “less than five days.” The therapy consisted of an odd mixture of belladonna (deadly nightshade), along with the fluid extracts of xanthoxylum (prickly ash) and hyoscyamus (henbane). These hospitals and wards attracted only the wealthiest alcoholics and addicts, who gladly paid exorbitant fees for a treatment that “successfully and completely removed the poison from the system and obliterates all craving for drugs and alcohol.” This was not the case unfortunately and many went on to relapse or die from alcoholism and drug abuse. As with anything in life, improper planning leads to poor performance. Getting off prescription pills is certainly no exception. A few things to consider when choosing when and where to get medically detoxed are insurance, cost, location, timing, and duration.
When choosing a medical detox, the first question and most important factor is how will a person pay for the treatment. There are multiple options and ways to pay but if one is not aware of these options frustration can deter them from moving forward. The first option financially would be to use health coverage. Health insurance as of right now is required to cover some form of addiction services. The extent of services each person’s insurance will cover can vary. For people with Medicaid or Medicare there are also options. Some of the detox facilities will be in hospitals while others will be in free-standing buildings. The average length of stay in a medical facility is seven to ten days. If a person does not have health care coverage they can expect to pay anywhere from $3,000.00 to $10,000.00 depending on the facility and its amenities. If health insurance is being used to cover the expense of detox, be aware of any co-pays and deductibles that may be required as an out of pocket expense.
Private facilities usually offer more amenities like acupuncture or massage therapy. Other amenities may include things like private rooms, saunas, pools, hot tubs and activity rooms. These things are obviously not necessary for detox. The most important quality to look for is having the medical staff to detox each person safely and effectively. Local hospitals that offer drug and alcohol detox may be a person only option, especially in rural areas. The process of detoxifying a person’s body is the same no matter where they do it. The only difference would be amenities. Again, the most important quality to look for is the experience of the facilities medical staff, including nurses and doctors. Both state and private detox centers use a mixture of either Methadone or the more popular Suboxone (also known as subs). Some places allow the use of benzodiazepines like Ativan for severe cases of withdrawal other medications commonly used are Librium, another benzodiazepine that is long acting. Clonidine, which is a blood pressure medicine commonly used to help suppress withdrawal symptoms. Promethazine or Zofran which helps sooth nausea symptoms. Ibuprofen or an equivalent for aches and pains. Seroquel is used to help with sleep. Most places will offer a variation of medications like these to help ease detox symptoms. Some places offer a variety of vitamins which can really speed up the recovery process since a person going through detoxification can be very vitamin deficient. Upon completion of the detox, there will be no more doses of Suboxone or Methadone, though some of the non-narcotic medications and vitamins may still be prescribed.
Some patients seeking treatment would prefer to be further away from ‘home’, while others want to be closer to friends and family. In some states there are a multitude of resources and in other states the options are slim. If a person is required to travel far from home to detox, make sure that the transportation is set up. Some facilities will pick patients up and drop them off at the airports. Ask what toiletries and possessions are allowed into the facility. Part of the medical detox process is to ensure that no one brings outside narcotics into the facility. This means luggage and personal belongings will be searched. Anything that has alcohol in it including mouthwash should be left at home.
After the detoxification process is completed, its time to return home, if there is no treatment plan set up afterward. Some people will opt to go into a rehabilitation facility if afforded the opportunity to gain a better foothold in sobriety. There may be some legal, personal or financial issues that need to be handled and most rehabs can help resolve those matters with its patients. This in conjunction with therapy and relapse prevention classes will help in the recovery process. If a patient isn’t going to treatment after detox it’s suggested to seek some form of counseling like self-help groups or finding a therapist with a background in addiction medicine. 12-step meetings, SMART recovery or some form of a support group is suggested.
Rapid Detox Process
Rapid opioid detoxification (ROD) was developed in the 1980s to reduce the length of hospitalization during detox. ROD is significantly different from traditional detox. Traditional detox can take days or weeks to complete and include the individual having to endure all the withdrawal symptoms with or without medication. During Rapid Opioid Detoxification, a doctor administers an oral opioid antagonist such as naltrexone in order to trigger withdrawal. After the medication is administered the withdrawal symptoms will come on violently. To combat this the doctor will administer moderate, intravenous oral sedation (also referred to as ‘conscious sedation’). While at the same time administering clonidine and other medications to ease withdrawal symptoms. This treatment is typically continued until all the opiates are excreted from one’s body. When the doctor is certain that the body is cleansed they can move on to the last step which sometimes is a drug called Vivitrol. Vivitrol can be administered by injection or implantation of a pellet that slowly releases the opiate-blocking agent. The shot lasts about a month and the implant is marketed to last three months. There are side effects with Vivitrol which include nausea, headache, dizziness, drowsiness, anxiety, tiredness, depression and loss of appetite may occur. If you have been using opiate narcotics regularly, mild opiate withdrawal symptoms may occur, including abdominal cramps, restlessness, bone/joint pain, muscle aches, and runny nose.
Anesthesia-assisted rapid opioid detox (AAROD) or anesthesia-assisted opiate detoxification (ultra-rapid opioid detoxification), on the other hand, is similar to rapid opioid detoxification but uses general anesthesia to complete the procedure in several hours. During AAROD, the patient is sedated and given drugs that trigger immediate withdrawal. If the individual was awake during this procedure, they would experience high levels of discomfort, but under the influence of the general anesthetic, they theoretically don’t feel any of the pain of withdrawal. When the patient wakes up, they have no memory of the process and their body is clear of any opioid substance.
Using medications to abruptly begin withdrawal has the potential to produce even more severe withdrawal symptoms in the individual, including vomiting, diarrhea, hypertension, and tachycardia (abnormally fast heart rate). Compared to anesthesia-assisted rapid opioid detox, ROD is more gradual and less risky than being placed under general anesthesia, but neither approach is endorsed by leading addiction medicine societies. In fact, there are many calls for further research into the safety and efficacy of these procedures. Also, post-acute withdrawal can last for months even if there are no opiates in an individuals body it depends on the history of usage like how long and how much opiates a person has used. Rapid Detox with or without anesthesia is not covered by insurance. The average cost of this procedure is $10,000 to $20,000. It’s very expensive and is known to have complications and a low success rate.
There are many ways to get off prescription opioids, the more knowledge one has the better. One person may decide to quit opiates once and for all on the couch. Others may decide to stay on a maintenance program whether that’s Methadone or Buprenorphine. There is no right or wrong way to quit opioids as long as it gets done. Each person has to decide for themselves which option will work best for them. The amazing thing about science and addiction medicine is that there are many options out there when it comes to getting off opiates. Some options are expensive while others are free.