Involves the use of medications, usually in combination with other behavioral or psychological interventions to increase likelihood of abstinence from more immediate acting opioids.
Methadone has been used clinically since the 1960s. It is the first medication to be approved to treat Opioid-Use Disorder (OUD). It is a full mu opioid agonist just like heroin, fentanyl, or oxycodone but has relatively strong receptor binding affinities and long duration of effect, therefore it works well for once daily dosing to prevent fluctuating toxicity levels or the onset of acute withdrawal symptoms. It is typically dispensed as a liquid at an opioid treatment facility. Because it creates a constant level of opioid receptor activation, it decreases the pathological brain response to drug cues and stress. The mood is not fluctuating based on drugs level changes and anxiety and depression are often maintained fairly consistently.
Those who continue to use heroin while on methadone usually experience very little euphoria from the drug because the methadone is competing with the receptors and "blocking" much of the effects from the heroin. For this reason, most people on methadone are not also using heroin. If the decision to go back to heroin is made, it usually followed by dropping out of the methadone treatment program.
In 2002 the FDA approved the use of buprenorphine in the treatment of opioid dependence. Buprenorphine is a partial mu agonist also with a relatively high binding strength to the opioid receptor. By doing so it has many of the same effects as other opioids simply to a less extreme degree. For example, it will enhance mood and decrease cravings like any other opioid would for an opioid dependent individual.
If taken by mouth, nearly all of the compound will be deactivated by the liver, therefore it is typically administered sublingually (under the tongue). The filmtab is placed under the tongue or against the cheek and left there until it dissolves completely.
Depending on the dose, the effects of the medication last for 1-3 days. When taken as prescribed and in appropriate doses, buprenorphine continuously activates the opioid system without producing euphoria or withdrawal. The effect is similar to what we see with methadone, however because buprenorphine is a partial agonist, its effect is less noticeable than methadone. The constant activation of the opioid receptors prevents opioid withdrawal and stabilizes the functioning of the opioid system. This reduces opioid craving. Patients treated with buprenorphine report improved mood and sleep and feeling "clear-headed." Also, because of its tight binding affinity, it will block other opioids if they are taken while buprenorphine is in the system.
Considering the safety of the two long-acting opioid medications, buprenorphine is a much safer option than methadone. Being only a partial agonist, the risk of extreme sedation or overdose is greatly minimized. Also, although it is contraindicated to do so, some people MAT will take benzodiazepine sedatives at the same time. When methadone is mixed with a benzodiazepine, the combination can be fatal.
Naltrexone has been used to treat OUD since the early 1970s, initially only as a tablet. In 2010, the FDA approved a monthly injection (Vivitrol). Naltrexone acts as an opioid receptor mu agonist with an extremely high binding affinity and can usually effectively block any opioid medication that is then consumed for up to two days (30 days for the injectable).
The most important consideration for naltrexone is that the individual must wait several days before all of the opioid is out of the system so not to risk immediate and precipitated withdrawal symptoms. Once the naltrexone is on-board, cravings for opioids are reduced and treatment can last indefinitely. Those who are concerned about sudden urges for heroin or other opioids and who do not trust themselves in the begging to maintain abstinence can find a huge benefit with naltrexone.
The debate over the use or non-use of opioid replacement therapies (buprenorphine or methadone) continues to be a very heated one. On the one side we can point to the devastating mortality rate from heroin or fentanyl-laced her heroin bags over the past ten years and methadone, for example, is certainly a better alternative to self-administering a bag of an unknown powder directly into your body. So in the short term - meaning a one to five year time period - this alternative will reduce the immediate catastrophe from the epidemic. The other side of the argument is that all research that extends its observations beyond the five year mark is fairly consistent in its finding that the ability for an individual to become completely free from all opioids becomes increasingly difficult the longer one remains on methadone treatment.
Because buprenorphine and methadone are controlled substances, diversion is going to be an issue. Both medications can be illegally rerouted to people who do not have a valid prescription. It is a not-so-secret secret in medication-assisted treatment facilities that some individuals will obtain their medication legally (with a prescription) and then sell it to someone else for money to use to buy illegal drugs. This undermines the entire system and to some degree affects everyone involved.
A few ways to prevent or reduce diversion are:
- Frequent urine tests to confirm the medication is being taken
- A pill count at each visit to be sure the right amount is left over
- Random callbacks for additional urine screens or pill counts
- Giving a limited supply of medication at one time
- Supervised medication administration at a licensed clinic.
Regardless of our personal beliefs about the most appropriate or effective way to begin or maintain an addiction recovery, we can all agree that all sufferers have the right to heal. Drug addiction is suffering - for the individual, the family, and the community. We can all agree that minimizing the suffering is an appropriate aim for treatment.
Recovering from drug addiction is an incredibly difficult and painful pursuit - we know this because the unfortunate truth is that most people never fully recover. Many of those who do find long-term comfort and a sense of community in the local twelve-step fellowship groups. Most of the individuals we have talked to who are currently enrolled in MAT choose not to participate in these groups because of the belief held by most members that the groups are only for people who are fully abstinent from all alcohol and narcotic products. What this means is that a lot of them attempt to work through their addiction on their own or at least without the immediate support of a strong fellowship. Like we discussed in detail in Rule #1, an attempt to recover from addiction on our own is almost certain to fail.
For this reason, Reaction Recovery takes no stance or opinion about the appropriateness of MAT to treat OUD. We know that ALL individuals can improve and move towards healing, renewal, and recovery with the structure of a disciplined routine and a personalized nutritional supplement regimen. This option needs to be available to everyone. Your journey is your journey, and we SEE you. You are not alone, and you do not need to muddle through the waters by yourself.
Reach out to us. Let us know how you are currently approaching your recovery and let us make us recommendations to help you move along the right path. However we choose to go about it, the ultimate goal of recovery is the same : establish a meaningful life of balance and purpose.