Medication-Assisted Recovery

Alcohol Dependency

Medications for Alcohol Dependency

Naltrexone: works by blocks opioid receptors in the brain that are involved in the rewarding effects of drinking alcohol, thereby reducing the number of heavy drinking days. Naltrexone is typically used with The Sinclair Method, which is a treatment protocol developed by Dr. John David Sinclair. It involves the use of the prescription drug naltrexone to reduce the cravings for alcohol. The Sinclair Method calls for use of naltrexone in combination with the patient’s normal drinking habits, that is, the patients do not need to go through Detox first, or abstain from drinking in the first phase of treatment. In fact, proponents of The Sinclair Method insist that naltrexone must be used in combination with drinking  to be effective. The process by which naltrexone is believed to work within The Sinclair Method is called pharmacological extinction. Naltrexone must be taken every day that the patient consumes alcohol, approximately one hour before the alcohol is to be consumed. By having naltrexone active in the body at the time alcohol is consumed, endorphins normally released by drinking are blocked, and over time, drinking loses its appeal.

Topiramate: is thought to work by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission. Topiramate is useful for reducing alcohol cravings and quieting the little voice that tells you “just one drink – no one will know but me”. It is usually very well tolerated by most patients and can be very helpful early in recovery for those patients who return to drinking because of cravings.

Acamprosate: acts on the GABA and Glutamate neurotransmitter systems and reduces drawn-out symptoms of abstinence such as insomnia, anxiety, restlessness, and the state of unease and dissatisfaction that comes with not drinking alcohol.

Disulfiram: also known as Antabuse, interferes with alcohol metabolism, resulting in accumulation of acetaldehyde, which produces a very unpleasant reaction that can include flushing, nausea, vomiting, headaches, chest pain, blurred vision, confusion, respiratory difficulty, and palpitations if the patient drinks alcohol. It does not stop cravings, but is used as a physical and psychological deterrent. Although it has been around for a long time, generally speaking, it is not effective for long term sobriety, but can be useful in high risk social situations to prevent a relapse.

Baclofen: the anti-craving, anti-anxiety, and anti-reward effects of baclofen relates to its effect on GABA-B receptors, which is also where alcohol has a major effect as it is one of the major pathways in the regulation of the reinforcing properties of drugs of addiction. It is very helpful for those patients who have extreme anxiety, either before they started drinking, or when they try to stop.

Gabapentin: approved for epileptic seizures and neuropathic pain, however, it also helps alcohol dependent patients stay away from alcohol because it improves mood, eases anxiety, improves insomnia, reduces cravings, and reduces the irritability associated with early recovery from alcohol.

Opioid Addiction

Suboxone® Therapy for Opioid Addiction

For some, a medical intervention to control cravings, in conjunction with counselling and 12 Step Programs, can be the difference between long-lasting sobriety and relapse.

Suboxone® is a combination of two drugs – buprenorphine which is a synthetic opioid partial agonist and naloxone a synthetic opioid antagonist. Buprenorphine is used to treat addiction to other opiates, for example codeine, oxycodone, hydromorphone, meperidine, morphine and heroin. It is more effective than methadone at curbing cravings. It is not useful in treating an addiction to cocaine, powder or crack, methamphetamine (speed), MDMA (ecstasy), benzodiazepines (valium and others), marijuana or alcohol.

Buprenorphine is effective in reducing the craving to use opiates and the symptoms of opiate withdrawal. Patients get a chance to get their lives back on track because they no longer have to spend considerable time and resources to find, use and recover from drugs. They now have an opportunity to separate themselves from the people and environments that promote drug use and other harmful activities. Buprenorphine can be effective whether you inject, snort or swallow other opiates. Several scientific studies have proven that addicts on an opioid maintenance program are less likely to have legal or medical problems and are more likely to hold down a job, stay in school and keep their family together.

How is Suboxone taken?

Suboxone is a sublingual (under the tongue) tablet taken once a day or every other day. Initially patients must go to a pharmacy frequently to get their medication. The pharmacist will witness the doses being taken. As they progress in the treatment program they will be given take doses home to take on their own, generally after two months of clean urine drug screens or when they are stable.  Patients are assessed weekly for several weeks and as they progress in their recovery, they attend clinic less often, usually once per month.

A Note on Starting Suboxone Treatment

Only specially trained physicians are able to prescribe Buprenorphine for Suboxone Maintenance Treatment (SMT).  Starting Buprenorphine is termed “Induction”. Starting Buprenorphine too early may put people dependent on opiates into precipitated withdrawal. Precipitated withdrawal is a rapid onset and intense withdrawal caused by taking Buprenorphine when you have still have too much opiate drugs in your system. Before the induction, the physician will ensure you are in a partial opiate withdrawal state and then slowly introduce Buprenorphine to your system over several hours. You will be assessed in the morning, reassessed at the end of the day, and checked again the next morning.

Methadone Therapy for Opioid Addiction

How Does Methadone Work?

Methadone can be used to treat opiate (morphine, Dilaudid, fentanyl, heroin) or “down” addiction, but it is not helpful for stimulant addiction such as cocaine (crack), Ritalin, or crystal meth (speed) or other substances of abuse.

Methadone is a strong opioid that is taken once per day as a liquid drink mixed with juice. It was originally used in the army for pain treatment during the Second World War, but it was discovered to be different from morphine, Dilaudid, and heroin (all types of “down”) in a few very important ways. These differences have led to their use in opioid addiction treatment for over 45 years. Methadone last a very long time in your body; about 1-3 days in fact. Most opiates last just hours. This means that you don’t get the highs and lows like you do with heroin, Dilaudid, morphine, and other types of “down”. Methadone also blocks the high you get using other opioids and prevents cravings with regular use. In this way, methadone helps people addicted to opiates to stop chasing their next fix, and get back to normal, healthy lives. However, methadone is just one of the tools used to help someone get off of opiates. Methadone is typically used in conjunction with addictions counselling and attending AA/NA or SMART Recovery meetings.

Effects of Methadone

The main effect of methadone for people is a reduced desire to use opiates. It helps stop cravings and need to use opiates. The effect is dose-related, and most will need to titrate up to 60-120mg a day before cravings are controlled. This is the recommended dosage for methadone maintenance an can take five to six weeks to reach.  Methadone can (but not always) cause:

  • Drowsiness, sleepiness, nausea, reduced energy
  • Reduced cough reflex and slower, shallower breathing
  • Reduction of any physical pain
  • Small pupils, constipation, dry mouth, lower blood pressure, and difficulty passing urine
  • Reduced menstrual periods, reduced testosterone levels in men, reduced sex drive and sugar cravings

Methadone and Suboxone FAQ

Effects and Side Effects of Suboxone

Euphoria (feeling high) or sedation is possible for the first few days if too high a dose of suboxone is taken. Typically patients feel no effect except a decreased need for opiates – a low dose is started for safety reasons. Stabilization is usually achieved over a few days (compared to a five to six weeks with methadone). During the stabilization phase some patients experience withdrawal and may decide to continue using to prevent these symptoms – using other opioids on Suboxone is not effective because patients do not get high because Suboxone blocks the euphoric effects of these drugs very efficiently – this helps to decrease the need to use opiates. Once stabilized, patients do not get intoxicated and do not suffer withdrawal or craving for opiates.

Most people get some side effects. Most common are constipation (typical of all opiates), dizziness or drowsiness. Withdrawal symptoms like headache, abdominal cramps, nausea, insomnia or diarrhea may be part of the induction phase but usually resolve once the patient is stabilized.

Taken as directed, Suboxone is very safe and does not have long term consequences, even after many years. Suboxone is not approved for use in pregnancy. Methadone is a suitable choice for pregnant women.

Will I become addicted to Suboxone/Methadone?

Patients taking Suboxone or Methadone are already physically dependent to opioids – stopping it will cause the uncomfortable physical symptoms of withdrawal. However, by definition these patients are not addicted to Suboxone or Methadone even though they are physiologically dependent – addiction involves not only a physical need for the drug (dependence) but several undesirable behaviors that a person develops to help them get the drug. These behaviors might include spending money that should go to your children, lying to your loved ones about where you are going, missing work, breaking the law, avoiding your friends and family, etc. Patients on Suboxone or Methadone maintenance have a steady supply of medication which blocks the need and desire for opiates therefore the patient has no reason to continue with these behaviors – many of which the patient is ashamed of or otherwise wants to stop.

Patients start to reform the spiritual emptiness and self-respect they have lost as a result of the addiction. They are free at any time to stop the medication if they want to or to slowly decrease their dose of Suboxone or Methadone which is the recommended approach as it is a more successful method of getting and staying off opioids. Many scientific studies have shown that Suboxone and Methadone Maintenance remain the most successful treatment currently available for opiate addiction. Both treatments are more effective with ongoing drug counselling and attending meetings such as AA/NA or SMART Recovery, a necessary part of recovery. If done correctly, it should take over a year to get off the medication, after the patient has stabilized in the other areas of their life.

In addition to stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain in treatment stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning.


Naloxone

Everyone will have experience with an overdose – from personal experience, work, or other sources. Some knowledge about how to respond may be incorrect, take more time, and can cause harm.

Unintentional deaths from opioid overdose are preventable with overdose and naloxone education. Naloxone, or Narcan®, is a pure opioid antagonist which will quickly reverse life-threatening respiratory depression of opioids to restore breathing, usually in 2-5 minutes. Naloxone is not a controlled substance, it cannot be abused, and in the absence of narcotics has no pharmacological activity. Research has shown having naloxone available does not increase risk taking behavior. Naloxone is a safe drug with minimal side effects, even less than an epi-pen.

What is Naloxone?

Naloxone is an antidote to an opioid overdose.

Naloxone is an injectable medication that can reverse this so the person can breathe normally and regain consciousness. Naloxone does not work for overdoses such as cocaine, ecstasy, GHB or alcohol. However, if an overdose involves multiple substances including opioids, naloxone will help by temporarily taking the opioid out of the equation. Naloxone is also known by the trade name Narcan®.

Naloxone Take Home Kits

Most pain medications are opiate or opiate derivatives. Opiates can cause severe, and sometimes fatal, depression of the respiratory system when taken in large doses, when mixed with other depressants or when a user’s usual tolerance has been compromised. Knowing how to respond to an opiate overdose, whether for prescription or illicit drugs, can save a life.

Take Home Naloxone (THN) programs provide naloxone to people who use opioids (legally prescribed or illegally obtained) and are at risk of an overdose. It is not intended to replace emergency care or minimize the importance of calling 911. But because 85% of overdoses happen within the company of others, having Naloxone offers the opportunity to save a life and reduce harms related to the overdose while waiting for the paramedics to arrive.

We encourage all opiate dependent patients, their family members, and their friends to have a Naloxone Take Home Kit.  A kit is available free at ICDO to all those that want one. If you would like to participate in this program, please contact ICDO at 778-471-6488.