Author: Charles Frank

Recovery is Possible: Treatment for Opioid Addiction Feature Topics Drug Overdose

Methadone and LAAM stimulate the cells much as the illicit opioids do, but they have different effects because of their different durations of action. Naltrexone and buprenorphine stimulate the cells in ways quite distinct from the addictive opioids. Opioid dependence and some of the most distressing opioid withdrawal symptoms stem from changes in another important brain system, involving an area at the base of the brain—the locus ceruleus (LC) (Figure 2). Neurons in the LC produce a chemical, noradrenaline (NA), and distribute it to other parts of the brain where it stimulates wakefulness, breathing, blood pressure, and general alertness, among other functions. When opioid molecules link to mu receptors on brain cells in the LC, they suppress the neurons’ release of NA, resulting in drowsiness, slowed respiration, low blood pressure—familiar effects of opioid intoxication.

Along with harm minimisation and psychosocial interventions, the mainstay of pharmacological treatment remains opioid substitution therapy (OST) using methadone or buprenorphine, with many patients receiving OST for many years. Even with these treatments, opiate users continue to face mortality risks 12 times higher than the general population, and emerging evidence suggests that individuals who remain on long-term OST present with a range of physical and cognitive impairments. Compared with other drugs of abuse, opioid dependence benefits from a wider range of available pharmacological tools for treatment. In spite of this, the large majority of the 1 million heroin addicts and 2 to 3 million prescription opioid abusers are not receiving treatment, and those who enter often only seek detoxification, from which early relapse is the most common outcome. The most successful treatment is long-term maintenance on agonists such as methadone and buprenorphine, but a variety of obstacles, including government regulations, cost, availability, and stigma, combine to diminish their use. The death rate among heroin addicts is approximately 2% to 3% per year, significantly higher than among their age- and socioeconomically matched cohorts.

Office visits once a week are usually recommended initially103 and can be reduced if the dose is stable, illicit drug use has stopped, and more intense psychological intervention is not needed. However, there may be practical obstacles to this, such as distance from the physician or problems paying for the medication and doctor’s visit if not adequately covered by insurance. Specific psychosocial interventions are implemented on an individual basis, taking into account the goal of the treatment package, the person’s needs and availability of trained staff and supervisors to deliver the intervention (Department of Health 2017). Initially the focus is on building a therapeutic relationship, identifying specific goals, identifying risks and creating a care plan with the patient to ensure that care can be delivered in a structured and cooperative manner.

Definitions of Key Terms

If sufficient abstinence is unclear, a test dose of a small amount of IM naloxone (eg, 0.2 mg) can be used.157,159 Any withdrawal produced will be short-lived. Naltrexone should be initiated with a dose of 25 mg and, if that produces no withdrawal, the second 25-mg dose can be given 1 hour later. If depot naltrexone is to be used, it is useful to have 1 to 2 days of a well-tolerated 50 mg oral dose. For oral naltrexone, virtually 100% adherence is needed because the blockade wears off around 24 to 48 hours after the last dose. There is no consensus on the best way to withdraw from buprenorphine maintenance other than to do it gradually, eg, 2 mg/week until 4 mg is reached and then 1 mg decreased every other week or monthly.

1. Despite this evidence and clinical guidelines, it is common to see lower doses prescribed in clinical practice.
2. In a meta-analysis by Sordo et al (Reference Sordo, Barrio and Bravo2017), the out-to-in all-cause mortality rate ratio per 1000 person-years in and out of treatment was found to be 3.20 and 2.20 for methadone and buprenorphine respectively.
3. Guidance on the optimal length of maintenance OST has still not been standardised and remains person specific.
4. By encouraging the patient to explore their goals and the discrepancies between their actions and appropriate behaviours to help attain these goals, this communication is thought to bring about self-sufficient behavioural change (Miller Reference Miller1983).

Be ready to answer questions so you’ll have more time to go over any points you want to focus on. While naloxone has been on the market for years, a nasal spray (Narcan, Kloxxado) and an injectable form are now available, though they can be very expensive. Methadone is orally effective, long-acting- thus producing smoother withdrawal – and safe, if care is taken with initial dosing. Please list any fees and grants from, employment by, consultancy for, shared ownership in or any close relationship with, at any time over the preceding 36 months, any organisation whose interests may be affected by the publication of the response.

Is chronic fatigue syndrome all in your brain?

Methadone treatment reduces relapse rates, facilitates behavioral therapy, and enables patients to concentrate on life tasks such as maintaining relationships and holding jobs. Pioneering studies by Dole, Nyswander, and Kreek in 1964 to 1966 established methadone’s efficacy (Dole et al., 1966). As a Drug Enforcement Administration schedule II controlled substance, the medication is administered primarily in federally regulated methadone programs, where careful monitoring of patients’ urine and regular drug counseling are critical components of rehabilitation. Patients are generally started on a daily dose of 20 mg to 30 mg, with increases of 5 mg to 10 mg until a dose of 60 mg to 100 mg per day is achieved.

Thus, several mechanisms in the LC and VTA-NAc brain pathways may be operating during addiction and relapse. The excitatory cortical pathways may produce little response in the VTA during the resting state, leading to reductions in DA. However, when the addicted individual is exposed to cues that produce craving, the glutamate pathways may get sufficiently active to raise DA and stimulate desire for a greater high. This same increase in glutamate activity will raise NA release from the LC to produce a dysphoric state predisposing to relapse and continued addiction.

Additionally, not all opioid agonists have the same mechanism and therefore cross-tolerance may be incomplete. This may help to explain why heroin use on top of opioid substitution therapy (e.g. methadone) can still result in fatal respiratory depression (Williams Reference Williams, Christie and Manzoni2001). The Food and Drug administration (FDA) approved sublingual buprenorphine in 2002 for office-based treatment for detoxification or maintenance of opioid dependence.

During the 1990s, there was a push by public health officials to improve pain treatment in the United States. This led to pain becoming the “fifth vital sign.” Doctors and nurses were given the impression that pain should be totally relieved. Narcotics are excellent pain relievers and too often they became the “go to” treatment for pain. Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition. Even after you’ve completed initial treatment, ongoing treatment and support can help prevent a relapse. Follow-up care can include periodic appointments with your counselor, continuing in a self-help program or attending a regular group session.

Involvement in self-help groups such as Alcoholics Anonymous or ( AA) or Narcotics anonymous (NA) should be encouraged. While such groups usually oppose agonist maintenance, naltrexone is often tolerated because of its lack of psychoactive effects. Urine tests should be carried out, if possible on a random basis, to see if the individual is using opioids, suggesting missing naltrexone doses, or has switched to drugs such as cocaine or benzodiazepines.

Clonazepam, trazodone, and Zolpidem have all been used for withdrawal-related insomnia, but the decision to use a benzodiazepine needs to be made carefully, especially for outpatient detoxification. To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account.Find out more about saving content to Google Drive.

Buprenorphine

The likely explanation for these observations is that opioids raise levels of cortisol, a hormone that plays a primary role in stress responses; and cortisol, in turn, raises the level of activity in the mesolimbic reward system (Kreek and Koob, 1998). By these mechanisms, stress may contribute to the abuser’s desire to take drugs in the first place and to his or her subsequent compulsion to keep taking them. Opioid tolerance occurs because the brain cells that have opioid receptors on them gradually become less responsive to the opioid stimulation. For example, more opioid is needed to stimulate the VTA brain cells of the mesolimbic reward system to release the same amount of DA in the NAc. Therefore, more opioid is needed to produce pleasure comparable to that provided in previous drug-taking episodes.

Rapid detoxification methods

In this situation, while naltrexone keeps the addictive opioid molecules away from the mu opioid receptors, clonidine may help to suppress the excessive NA output that is a primary cause of withdrawal (Kosten, 1990). Many patients with chronic pain can be treated with buprenorphine doses of 24 to 32 mg divided into 3 or 4 daily doses and supplemented if necessary by nonopioid analgesics. If pain relief is not sufficient, or the patient is resorting to illicit opioid use to control it, transfer to methadone maintenance may be needed. The underlying principle of OST is that administering an opioid medication with a longer half-life than illicit opioids will lead to complete cessation of illicit opioid use while also avoiding opioid withdrawal syndrome. Its long half-life (~24 h) compared with heroin (between 5 and 30 mins) means that it is less likely to result in withdrawal symptoms and cravings. After discussion with you, your health care provider may recommend medicine as part of your treatment for opioid addiction.

Discontinuation of buprenorphine maintenance

This has been demonstrated by the differential effects on overdose deaths in France of methadone and buprenorphine.112 The ceiling effect is approximately 32 mg of sublingual buprenorphine, but it may be possible to increase analgesic effects above that. In 2002, the FDA approved buprenorphine for the treatment of opioid dependence in office-based practice. Physicians need to receive 8 hours of specialized training in person or online, and then apply for a waiver from the Department of Health and Human Services. They are limited to 30 patients on buprenorphine for the first year, and can then apply to increase the number to 100. Compared with methadone-aided withdrawal, clonidine has more side effects, especially hypotension, but is less likely to lead to post-withdrawal rebound. In a study of heroin detoxification, buprenorphine did better on retention, heroin use, and withdrawal severity than the clonidine group.12 Since clonidine has mild analgesic effects, added analgesia may not be needed during the withdrawal period for medical opioid addicts.

A third variation on the set-point change emphasizes the sensitivity to environmental cues that leads to drug wanting or craving rather than just reinforcement and withdrawal (Breiter et al., 1997; Robinson and Berridge, 2000). During periods when the drug is not available to addicts, their brains can remember the drug, and desire or craving for the drug can be a major factor leading to drug use relapse. This craving may represent increased activity of the cortical excitatory (glutamate) neurotransmitters, which drive the resting activity of the DA-containing VTA neurons, as mentioned, and also drive the LC NA neurons. As the glutamate activity increases, DA will be released from the VTA, leading to drug wanting or craving, and NA will be released from the LC, leading to increased opioid withdrawal symptoms. This theory suggests that these cortical excitatory brain pathways are overactive in heroin addiction and that reducing their activity would be therapeutic. Scientists are currently researching a medication called lamotrigene and related compounds called excitatory amino acid antagonists to see whether this potential treatment strategy really can work.