by Peter R. Coleman, M.D.
Recently, The Huffington Post published a lengthy article by Jason Cherkis on the various methods to treat patients with opiate dependence. It was an excellent article that featured a number of personal cases from families who had lost loved ones to an opiate overdose. In almost all of the cases, the overdose had occurred shortly after the patient had tried to get clean and sober.
The main message of the article seemed to be that traditional treatment programs don’t work well for opiate addiction and the only effective way to treat people who have this problem is to put them on agonist therapy, such as Suboxone®.
(An agonist is a chemical that binds to a receptor and activates the receptor to produce a biological response. Whereas an agonist causes an action, an antagonist blocks the action of the agonist and an inverse agonist causes an action opposite to that of the agonist.)
The article indicated that Methadone, an agonist, could be a good treatment for opiate addiction, but Suboxone® seems to be better. Cherkis interviewed the Medical Director of the Hazelden Treatment Program – a traditionally abstinence-based treatment program – who implied that Hazelden had recently started putting all of their patients with opiate dependence onto Suboxone® and was recommending that patients stay on this medicine after discharge.
I have been working with patients who suffer from opiate addiction and studying this issue for the last 30 years. I have a number of observations and thoughts to share:
Recovery from opiate addiction is very difficult and success rates with traditional treatment are low. Opiate dependence seems to have a much higher relapse rate and the consequences of relapse can be devastating. For a long time, we have known that overdose can easily occur after any period of abstinence. If an alcoholic relapses, it can be painful and difficult for all concerned, but if a heroin addict relapses, it can be fatal.
It can be much easier to treat patients with alcoholism. Traditional treatment programs have a high success rate with alcoholics - around 60 – 70% - but, they have a much lower success rate with cocaine and/or opiate addiction/dependency. Some reports indicate treatment success with opiate dependence can be as low as 10%.
It is not entirely clear why the success rates are so much lower for opiate addiction. There are undoubtedly many factors. The main one seems to be the intensity and the length of time that individuals experience Post-Acute Withdrawal Syndrome (PAWS). When people stop using OxyContin or any other opiates, they go through a 7-10 day acute withdrawal period, followed by another period of time before they feel back to normal. During this Post-Acute Withdrawal Syndrome period, they have intense cravings, insomnia, and a profound lack of energy. The temptation to use “just a little bit” can be overwhelming and many people give in to the temptation.
Cherkis is correct. Traditional treatment programs do not do well. Even after 28 days in a treatment program, many people relapse as soon as they are back in their normal environment with all of its triggers, both emotional and physical. Outpatient programs have difficulty keeping people coming to their classes because opiate addicts usually relapse and stop showing up for appointments.
Cherkis advocates putting most patients on an agonist, such as Methadone or Suboxone®. These medicines are clearly the best answer for some people and are definitely better than using street drugs. However, these treatments have their own problems.
Many patients drop out of treatment and don’t make any progress. Many patients abuse the Suboxone®, continue to use other drugs, sell the drugs, and continue to use opiates. Most studies of Suboxone® and Methadone report up to 70% of patients in treatment continue to use opiates or other drugs. Many patients simply don’t like being on these Methadone or Suboxone®. Most patients, given the choice, would much prefer to be completely free of drugs.
In order to help patients become completely drug free, many treatment programs are changing. Over time, we have learned that the first six months of sobriety is the critical period when it comes to opiate dependence. We need and must help people through this period in order to get onto the road of long-term recovery. Many inpatient facilities are now referring patients to an outpatient counseling program directly after their inpatient treatment. Many patients are now moving into a halfway house for the first 6 – 12 months after treatment.
At TCI, our patients use Naltrexone implants or monthly Naltrexone injections. Naltrexone is a powerful antagonist that dramatically reduces cravings, prevents relapse, and allows patients the freedom to more fully participate in treatment. We have found that a combination of Naltrexone therapy and intensive treatment is very successful in helping patients stay clean for the long term.
I believe that all patients can achieve long term recovery if they work hard for it, but they often need some medication assistance to be successful. Rather than putting patients on another addictive drug, we believe many patients can achieve long term sobriety with the aid of Naltrexone.
Patients need a choice.
For some, Suboxone® can be a good maintenance treatment, but for many, the combination of Naltrexone therapy with a commitment to intensive and effective recovery work is very successful towards achieving abstinence.