Opiate Addiction - Some Basic Q & A

Why are some people more susceptible to addiction than others?

Susceptibility to addiction is complicated and complex. About 50% of one’s susceptibility is genetic, mostly related to a person’s dopamine receptors and opiate receptors in the brain. It seems that people with fewer dopamine receptors are more prone to becoming addicted to opiates because opiates stimulate dopamine release.

The other 50% of susceptibility comes from environmental and other patient factors. The presence of a mental health disorder such as depression or bipolar mood disorder greatly predisposes a person to becoming addicted to opiates. Home environment, including the presence of abuse, can pre-dispose a person to addiction. Socio-economic status and the amount of education also play a large role.

If one is addicted to opioids, what are their treatment options?

The American Society of Addiction Medicine has outlined four different levels of care for patients with opiate addition problems. These levels of care range from 1) outpatient treatment programs including individualized therapy and group therapy, 2) intensive outpatient treatment, otherwise known as IOP (9 hours a week) or partial hospitalization programs, 3) inpatient services such as inpatient rehab and 4) medically managed inpatient services for those patients who also need medical stabilization. Usually an addiction treatment provider can perform an initial intake on a patient and determine what level of care the patient needs. Many patients can do just as well with outpatient treatment as with inpatient.

In addition, patients with opiate use disorders have two basic options:
Option 1
Patients can go on to medication assisted therapy (MAT), also known as opiate replacement therapy (ORT). With this option a patient is converted to either methadone or buprenorphine. Both of these medications are opiates, however, they do not produce the “high” that patients typically feel with traditional opiates like oxycodone or heroin. Methadone and buprenorphine can be long-term solutions, and being on either of these medications for years causes very little major problems.

Furthermore, being on MAT greatly reduces relapse, reduces the incidence of communicable disease (believe it or not, patients with opiate use disorders frequently inject their drug of choice intravenously and frequently use “dirty” needles, contaminated with hepatitis C or HIV). Stopping MAT greatly increases the risk of relapse.

Methadone used for patients with opiate addiction can only be prescribed by licensed methadone treatment facilities. So taking methadone for opiate addiction can be cumbersome – the patient has to typically go to the methadone clinic every day for their dose of methadone. This is because methadone is a very strong narcotic, and can be abused by patients and can lead to overdose.

Buprenorphine was approved for use in the treatment of opiate addiction in 1982. It is a “partial” opiate, so it is safer to use than methadone. It much less frequently leads to overdose and patients typically cannot get a full euphoric effect from it. Simply put, it mainly prevents the horrible withdrawal symptoms patients get from stopping opiates.
Since it is safe, the DEA has allowed physicians to prescribe it in their offices, once the provider has gone through a special training class. Providers can prescribe enough buprenorphine to last for several weeks to several months.

Buprenorphine also comes in an implantable form. The buprenorphine implant can be placed under the skin of the upper arm and will provide a constant amount of medication for over 6 months and in most cases much longer, even up to a year. This greatly helps patients in that there is no daily medication to take. 

Option 2
Patients can use medication to stop using opiates completely. Typically patients are given medications to make going through withdrawal from opiates more comfortable. When patients abruptly stop opiates they typically go through withdrawal, which can include severe muscle aches, severe agitation, nausea, vomiting, and diarrhea. Doctors can use medications to minimize these symptoms. After the withdrawal period is over (typically in about 5 to 7 days) patients are started on naltrexone therapy. Naltrexone is an opiate blocker. It blocks all the effects of opiates. Naltrexone comes in extended release intramuscular injectable form, which lasts in the body for 28 days. So as long as the patient comes in for the injection every 28 days, the patient is “protected” from the effects of opiates, both the euphoria effects and the harmful effects. And naltrexone greatly reduces cravings for opiates. Naltrexone also comes as an implant that can last in the body for 2 to 6 months, depending on the implant, conferring to patients a much longer period of protection from opiates. 

How do you specifically work with patients?

I am an outpatient addiction treatment specialist, focusing only on the outpatient treatment options, including medications as well as therapy.

I use both options listed above. I treat patients with buprenorphine including the oral, daily buprenorphine, the newer monthly injectable form called Sublocade, and the buprenorphine implant Probuphine.

I also provide the option of getting a patient off of all opiates and onto long-acting naltrexone, including both the intramuscular 28-day naltrexone as well as the naltrexone implant.

In addition I provide an accelerated outpatient “detox” program. Patients trying to stop their opiate use are typically going to go through a severe withdrawal syndrome for up to 7 days. We use a combination of 7 medications to make patients much more comfortable during the “detoxification” period as well as to shorten the period to 3 to 4 days. 

Why are doctors still prescribing opioids if we now have an epidemic?

Opiates are appropriate medications when used correctly. They should be used to manage acute pain after injuries or surgeries, but should not be used on a longer term basis. It takes less than a week to become addicted to an opiate when it is used on a daily schedule. So opiates should be only taken for several days and then discontinued.

Also, chronic pain due is a real problem. Many patients do have chronic orthopedic pain or cancer-related pain that needs to be treated with opiate medication. And many patients do well on long-term opiate medication without developing addiction. These patients do develop dependence, meaning they can’t stop the medication or they will go through withdrawal. But these patients can function normally, go to work, have normal social relationships and do not show the typical signs of addiction.

What is the first step someone with an addiction should take once they’re ready to acknowledge they have a problem?

Patients should seek help.  There is currently no central location to look for help, so patients need to be resourceful. A good idea is to probably get the help of a trusted friend of family member. Addicts frequently are not thinking clearly. Find a trusted person to help. Look online for addiction treatment providers. Understand that outpatient treatment has been proven to be equally effective as expensive inpatient treatment. 

Patients should not try to stop using opiates on their own. While typically not life-threatening, withdrawing from opiates without medical assistance is dangerous and extremely uncomfortable.

I am currently working with the Colorado Society of Addiction Medicine to develop a page on their website that can explain treatment options to patients, outpatient versus inpatient, detox, recovery, individual vs. group therapy. Addiction versus dependence. These terms are so foreign to most people. Having a trustworthy centralized source of information and treatment options will be helpful.

Explain the term “dope sick.”

Patients who become addicted to opiates do so in order to get the “high” that opiates initially provide. They keep coming back to the opiate to get the same high, but that initial high is harder and harder to achieve because patients become tolerant to the effects of opiates. In other words, it takes more and more of the same drug to achieve the same level of euphoria. But patients don’t just develop this tolerance to opiate, they also develop “dependence,” meaning the brain has essentially been hijacked by the opiates. The opiates change the brain’s chemistry such that once this happens if the patient does not take their daily dose of the opiate the patient is going to go through withdrawal. 

Eventually, after prolonged use of opiates over months, the patient stops getting the “high” that they initially achieved with the opiate, and start using the opiate just to prevent becoming “dope sick.” Dope sick is really just the severe withdrawal symptoms that patients experience when their body has developed a dependence on the opiate. It includes severe agitation, anxiety, body aches, and muscle spasms. It also can include severe vomiting and diarrhea and sleeplessness. Patients will do anything to avoid becoming dope sick, including finding easier opiates to use, such as heroin.

Let’s talk about the government’s declaration of an opioid epidemic. What’s changed since the announcement?

The government has relaxed its rules on how many providers can provide buprenorphine. It has expanded treatment prescribing of buprenorphine to physician assistants and nurse practitioners. It has offered grants and subsidies to treatment providers to get the mandatory training class that is needed in order to be able to prescribe buprenorphine. The government also regulates how many patients a treatment provider can have on buprenorphine. Previously the limit was 100 patients and the government has expanded this now to 275 patients. So it is trying to make access to buprenorphine, one of the mainstays of Medication Assisted Therapy (MAT) easier for patients. 

I suspect that we are going to see more grant monies coming from federal and state resources to additionally help with the crisis.

State legislatures are also paying more attention to the crisis. In Colorado, according to the Denver Post, opiates kill someone in Colorado every 9 and ½ hours. According to the same article Colorado received an additional $35 million to be put towards solutions for the epidemic. Some of that money is going to research. I suppose we first have to understand the problem in order to try to fix it. 

Some of the legislation currently being considered in Colorado is to have prescribers limit the amount of days of opiates given to patients to less than 7 for patients that have never taken opiates before. Also having prescribers be required to check the State’s database, the Prescription Drug Monitoring Program (PDMP) to see a patient’s history of opiate prescriptions. Finally the State is considering giving prescribers “report cards” to see how their prescription patterns align with other prescribers. 

Why do we have an epidemic in the first place?

This is complicated and not easy to sort out. 

Pharmaceutical Companies: 
15 years ago drug companies who made prescription opiate medications were telling providers that the medications they were making were not addictive.

Government: 
The Joint National Commission, the organization that accredits hospitals and facilities, and CMS (Centers for Medicare and Medicaid Studies) added “Pain” as a vital sign in 2001. So in addition to measuring a patient’s blood pressure, pulse, temperature, respiratory rate, etc. providers, hospitals and facilities were mandated to treating a patient’s pain. Providers, hospitals and facilities who did not do that were looked at unfavorably. CMS even continues to have patient satisfaction scores related to pain and will adjust reimbursement levels to providers based on how well a patient’s pain is treated. Not surprisingly with this linkage of pain treatment to reimbursement, providers began to treat pain more aggressively, and also not surprisingly, this is when the opiate epidemic started. 

Economic Crisis:
In 2007/2008 the economic crisis hit the country really hard. Many people were out of work and looking for an easy way to make money. For many pain pills were the answer. Patients on state-sponsored Medicaid programs can get prescriptions of opiate pain medications for $2 - $3 per month. Imagine, go to your doctor and get 60 oxycodone 10 mg tablets for a total of $3. Each pill can be sold for $10. The whole bottle can be sold for $600! It is an easy scam for patients to pull off at the doctor’s office. Chronic back pain, chronic orthopedic problems. Government telling providers to treat the patient’s pain. Pharmaceutical companies telling providers the medication is not addictive. This was easy money for a lot of patients. Throw in unscrupulous providers who would prescribe more opiates than required and this was and in some parts of the country continues to be a recipe for disaster.

Heroin is usually what an addict will go to next. Why? How is it the same and how is it different from opioids?

Heroin in cheap. It comes directly from the poppy plant which is grown extensively in Mexico, so it is easily transported to the US. It has a very rapid onset of action and a short half-life and is converted very quickly to morphine and 6-acetyl-morphine, both of which are powerful narcotics. Drug dealers from Mexico have set up elaborate distribution systems. The dealers are nice, well-dressed and frequently give free samples. They have learned that customer service goes a long way towards keeping people addicted to heroin. 

How do we fix the crisis?

It is going to take a concerted effort on the part of many parts of our society, including government, medication prescribers, law enforcement and schools. We need to provide more education to middle school and high school kids about the perils of becoming addicted to opiates. Providers need to change prescribing behavior to give fewer days of pain medication and educate patients on the dangers of opiate use and how quickly addiction and dependence develop. Providers also need to check urine drug screens and check the PDMP on a consistent basis to look for irregular patterns of drug use by patients. Governmental agencies need to allow more providers to treat patients for opiate use disorders and need to provide more funding for relatively inexpensive outpatient treatment options. We need to educate providers and addicts about the benefits of long-term naltrexone therapy as a way to prevent relapse. Law enforcement needs to continue to do its job of reducing supply of illicit drugs including heroin, fentanyl and others. 

It sounds like recovery is a long process, and costly. How can people get help both emotionally and financially?
Recovery is lifelong. I haven’t met an ex-opiate user yet who hasn’t told me that. Coming off of opiates can be costly if done in an inpatient treatment center. But it doesn’t have to be. Outpatient withdrawal symptoms management has been proven to work just as effectively as inpatient, and costs much less. Ongoing recovery can be emotionally draining but it doesn’t have to be expensive.  There are Narcotics Anonymous and Smart Recovery groups. Phoenix Multi-Sport offers exercise-based recovery group meetings. All of this is free. Ongoing naltrexone therapy does have an expense but much less than ongoing opiate use. Methadone and buprenorphine used in MAT programs can also have a cost, but again, much less so than continuing with opiate addiction.