Why medication assisted treatment?
To understand how medication assisted treatment works we must first understand the basics of addiction. Nobody starts out as an addict; people start opioids either as prescribed from a doctor or recreationally to get “high”. They continue to use because it feels good and because opioids activate the reward center in the brain that releases dopamine to produce feelings of euphoria that are normally released during exercise, eating and sex. With continued use, other areas of the brain start to form conditioned memories that associate the good feelings with the circumstances and environment in which they occur. This becomes important in recovery as these conditioned memories lead to craving for the drug when the person is around the same people, places or things.
Over time, the brain adjusts to repeated exposure to the substance so that it functions normally when drugs are present and abnormally when they are not. This leads to escalation in dosage in order to get the same pleasurable effects, otherwise known as tolerance. Higher tolerance levels cause the brain and body to become dependent on the drug to maintain their new norm. Dependence occurs after significant brain changes have developed, so that without the drug the brain can not function normally leading to a wide array of unpleasant withdrawal symptoms. Withdrawal symptoms include nausea, vomiting, diarrhea, chills, muscle aches, pains, tremors, anxiety and agitation. These symptoms become so unpleasant that avoidance of them eventually becomes the reason for continued usage despite negative consequences.
Medication assisted treatment employs a variety of medications that either help to suppress withdrawal or inhibit the pleasurable effects of opioids. Medications that help to suppress withdrawal are long-acting formulations of opioids that weakly activate the opiate receptors preventing withdrawal and cravings without the euphoria that is obtained from shorter-acting full opioid agonists. Medications that inhibit the pleasurable effects of opioids are complete opiate receptor blockers and prevent euphoria by preventing opioid receptor binding. Examples of some of the current medications used in medication assisted treatment are explained in detail below.
Suboxone vs. Methadone vs. Vivitrol
There are 3 main treatment options available for opioid addiction are Suboxone, Vivitrol and Methadone. Each has its own advantages and disadvantages and you should speak to your medical doctor about your condition so they can help you decide what your best option would be. Any medication assisted plan should be supplemented with regular counseling sessions and active participation in recovery. The amount of time on medication assisted therapy should be determined according to your goals and in close coordination with your physician. We recommend that most people stay in the program for 1-2 years which gives them time to stabilize and achieve their immediate goals. After the patient has stabilized, a medically supervised taper is scheduled at a rate where minimal withdrawal symptoms are noted until the person is weaned off or to their lowest effective dose.
Suboxone is composed of Buprenorphine and Naloxone in a sublingual or tablet form. Buprenorphine is a long acting partial opioid agonist which means that it binds loosely to the opioid receptors partially activating them. This helps to control withdrawal symptoms and cravings by producing less euphoria than a full opioid agonist. When on the correct dosage it does not allow any other full opioid agonists to bind to the receptors preventing their effects. It is safer than most opioids as it does not produce respiratory depression which is the most common cause of death from overdose. It is commonly combined with Naloxone that produces withdrawal symptoms if a person were to attempt to crush, inject or snort the medication. There is a ceiling effect that occurs where past a certain point there is no further increase in the pharmacological effects of the medication except increased withdrawal suppression and opioid blockade. These properties make it a common medication used in detoxification from opioids in detox and rehab centers. The cost of the medication is about $8-$10 for an 8/2mg strip and is prescribed by a DATA-waivered physician. Dosing is usually 8-16mg per day with a maximum of 24mg per day.
Methadone is a long acting full opioid agonist developed in the 1940’s in Germany. It is an inexpensive drug that is commonly used in medication assisted treatment to help decrease cravings and withdrawals symptoms from heroin and other opiates. The average daily dose ranges between 80 - 120-mg and there is no maximum amount. It has a half-life of 15 - 60 hours which varies individually by genetic variability of the liver’s cytochrome enzymes that are involved in drug metabolism. Some people called ‘fast metabolizers’ may need to be on a higher dose while others may only need to take the medication every next day to get similar effects. It is usually given on a daily basis at special treatment centers that offer counseling and other social services. Because of it is a full opioid agonist it can be a good choice for people who are battling addiction and have chronic pain. As with other opioids, tolerance and dependence can develop which is why counseling is a vital part of the recovery process.
Methadone has been the drug of choice for pregnant women with opioid addiction to help minimize any withdrawal symptoms that may precipitate miscarriage or premature birth, however the medication is not without risks. Similar to other opioids there is a risk of respiratory depression and overdose especially if mixing methadone with benzodiazepines. There is also risk of potentiating Long QT Syndrome which is why it is important for your physician to thoroughly review your current medications and past medical history before starting the medication. Methadone is tightly regulated and strict guidelines require initial observed daily dosing and required counseling sessions. This makes it a good option for those who are at higher risk of relapse and require a more structured environment.
Vivitrol is the injectable form of naloxone which is an opioid antagonist. It is a once-monthly injection administered in the gluteal muscle after the patient has completed a 7-10 day detox from opioids. It works by binding tightly to the opioid receptors thereby blocking any other opioid in the system. It is important to note that it does not stimulate the opioid receptors so there are no opiate effects, no tolerance, dependence or risk of respiratory depression. It works by competitive inhibition by occupying the opioid binding site so no other opioids can bind. It binds so tightly that if a patient has not completely detoxed before getting the injection they may experience a ‘precipitated withdrawal’ when the naloxone competes and knocks off any existing opiates on the binding site. The ideal time to get a Vivitrol shot would be after completion of a rehab or detox as administration requires a 7-10 day drug free interval. The medication costs ~$1400 and must be special ordered from specific pharmacies. Luckily most insurance plans do offer coverage. The pharmacy would coordinate benefits with your Vivitrol provider to determine shipping and coverage. This is a great option for working professionals who require clean drug screens and want to avoid the temptation of relapse.