Medication Assisted Therapies for Addiction

Foreign. We are getting ready to get started. I do want to kind of start out by, well, obviously welcoming, welcoming everybody. But I know this is a touchy topic or a charged topic for a lot of people. And my goal is not to, you know, advocate one way or another because treatment is appropriate. Different treatments are appropriate for different clients. But I think it is important that we're aware of it, number one, because it is an option for certain clients and because some of our clients are going to be on medication assisted therapies from other physicians or other clinics and we're going to have to know how to deal with that. So. I'd like to welcome everybody to today's presentation on medication assisted therapies for addiction. I AM your host, Dr. Donnelly Snipes. Today we're going to discuss the purpose of long term pharmacotherapy and identify pharmacotherapies that are out there and available for smoking, alcohol and opioids. Why medication assisted therapy? Well, let's think about our clients. Some clients have difficulty staying clean and sober during that early recovery period because their neurotransmitters are so out of balance. If they had been relatively, quote, stable on the drugs that they were using, then we know that, you know, it'll take time for their body, for their brain to get the message that, hey, this isn't being introduced to the body anymore. So we need to start, you know, making our own endogenous opioids and things like that. But that takes time. Some clients have a really hard time dealing with the cravings and staying clean and sober without some sort of assistance. And, and it's not always methadone or suboxone. There are a lot of medication assisted therapies out there that are there to do exactly that, assist people who have difficulty, especially in that early recovery period, the first year to 18 months, maybe in early recovery. Medication assisted therapy reduces cravings. Well, that's helpful especially if the person is not in residential. If they're an outpatient, they may be in your clinic. Even if they're in intensive outpatient or PHP, they're only in your clinic for maybe six hours a day and the other, you know, 18 hours a day or whatever that they are not in, in clinic, they're having to struggle with their cravings and those cravings can feel very, very overwhelming. Especially in early recovery. Medication assisted therapy provides increased senses of self efficacy and a greater sense of control because clients can leave your office after intensive outpatient and stay clean, have more success at dealing with their cravings through the rest of the hours until they show up the next day. And this helps people start seeing, seeing how they can potentially live a life without using. There's anxiety reduction because it can alleviate some of the anxiety or fear about relapsing. A lot of times people don't just start out with medication assisted therapy. A lot of times people try other ways of recovery, they try other treatment programs. And medication assisted therapy may be a intervention that comes along later in their process because they're having difficulty staying clean and sober. It doesn't mean that has to be the way. But every person is going to be different. And medication assisted therapy for the majority of people, like 98 point something percent, the majority of people on medication assisted therapy are only on it for, for a period of a year to two years, maybe a little bit more. But when I was working in the opioid treatment program in, in Florida, if somebody was going to be on medication assisted therapy with opioids past two years, we had to actually write a appeal to get permission to keep them on it for, for more than two years. Now the same is not so true with Suboxone and, and buprenorphine and we'll get into that in, in a little while. But medication assisted therapy is there to help people get clean and sober. It's there to make that transition easier. For some people. The pharmacological effects of certain medication assisted therapies can also help with anxiety reduction. If it is a partial opioid agonist, which means it turns, turns that lock, turns on those opioid receptors just a little bit, then that can have a calming effect on the person which can reduce their anxiety, which a lot of times they were self medicated, self medicating with the opioids. It may improve depressive symptoms by enhancing hope and a sense of empowerment. And again, the pharmacological effects of certain medication assisted therapies, we're finding that because there is such a strong connection between systemic inflammation and pain and depression that some of the opioids that people abuse actually help them feel less depressed. And you know, we're not going to talk about a lot of those today because they are not approved by the FDA for medication assisted therapy. But we do always want to ask ourselves, and maybe the client, why is it that you chose this drug? What does it do for you? Because different drugs do different things because they attach to different neurotransmitter receptors in early recovery. You know, we're talking about the first three months. We want to reduce co occurring issues. People are going to have a dickens of a time staying clean and sober. If they are super anxious, if they're super depressed, if they can't go, or if their cravings are so strong they can't focus on anything else, we need to help them get to a place where they can function. We need to identify and address vulnerabilities for relapse. This is where we start making that relapse prevention plan. What things trigger your cravings, what things help you feel less anxious, less depressed? We want to help them improve their overall health through sleep. You know, education about sleep hygiene and, and just sleep in general. We want to make sure they're, they have access to adequate nutrition. The neurotransmitters in early recovery are just way out of balance. The body has been exposed to a lot of stressors. And that HPA axis, our threat response system has just been going haywire because as we as, as people take drugs, that's way more than the body's used to having. So that's a stressor on the HPA axis. And as they detox, as they start experiencing withdrawal symptoms, that's another stressor on that HPA axis. So the HPA axis has just been wide open and we need to help them help their body recover. It's important. Important. And energy is another thing we want to see. We want to encourage people to start maintaining a routine to get their circadian rhythms kind of in balance again so they can, their body knows when to secrete cortisol and when to secrete melatonin. We want to help them develop more energy instead of feeling so depressed or in pain or, you know, whatever causing their fatigue. We want to help them start addressing those issues. We want them to maintain abstinence. You know, this is a biggie because, you know, we, we don't want them to be abstinent for three or four days and then relapse and then, you know, have to detox again. That is just putting the HPA axis and all those neurotransmitters and the body and the brain in general on a huge roller coaster. Yo, yo, whatever analogy you want to use, we want to increase the time to relapse. This doesn't mean that we are going to prevent relapse completely. Ideally, yes, that's always the goal. But we definitely want to increase the time to relapse. If somebody goes, you know, an additional month past, you know, when they'd been able to stay clean and sober before, maybe prior, they'd been able to stay clean and sober for Maybe three months. And with medication assisted therapy, they're able to stay clean and sober for six months before they relapse. Well, that's doubling the amount of time they were clean and sober. So they developed more skills, they developed more tools, hopefully during that time. And we want to reduce the intensity of binging if a relapse does occur. Some of these medications make it really unpleasant to use, which obviously are going to reduce the intensity. The go goal is not to substitute one drug for another to give them a quote legal high. The goal is to take the edge off or put things in place. So using is unpleasant. Part of a comprehensive plan that addresses early recovery also focuses on emotional, cognitive, physical, social, occupational and environmental issues. It's not just give somebody a pill and you know, see you later or a sublingual or whatever it is. We want to make sure that people are getting the skills and tools they need to stay clean and sober. That way, you know, In a year, 18 months, they can start to be titrated off the medications unless they're using it. There are some people who are, who have, you know, severe chronic pain issues that may be on certain medications for the rest of their life, but they're the exception to the rule most of the time. The goal is to use the medication assistance to act as a support for people while they're developing these new tools to help them develop successes, to help them develop a sense of self efficacy. And then as they're titrated they slowly realize that hey, you know, I'm doing this and I don't need those medications anymore. It is not a substitute for counseling. We, I know, I've said it like three times already and this is so important because too often I see people going places and getting medication assisted therapy, but not partaking in counseling. So all they're doing is, you know, taking the edge off so they're not having to use illegal drugs. But they're also not getting any better. They're not addressing the underlying issues that maybe prompted them to use in the first place. Pharmacotherapy definitely works best in combination with psychosocial support. Remember that co occurring disorders are the expectation, not the exception. Exception. Most people who are in addiction recovery or a significant proportion are going to have co occurring issues. And think about it, when you've been using and you've gotten your neurotransmitters all all mucked up, it's you're probably going to have difficulty with happiness, with sadness, with anger, with anxiety. You know, those emotions may come out at weird Times because the brains neurochemicals are out of balance because of what people do when they're in their addiction. A lot of times people feel guilty or grief stricken about what they've done or the consequences of what they they've done. In early recovery, when they're dealing with that, they are often anxious, depressed, grieving, feeling guilty. There's a lot of emotions there and, and we don't want to minimize that. Somebody who is sobering up and recognizing the damage that they've left in the in their wake is probably going to experience a significant amount of depression. And we can't ignore that. Somebody that's that depressed or feeling grieving or feeling that guilty, whatever label they want to put on it, it's going to have a hard time staying clean and sober. They may feel, you know, what's the point? Look at all I've lost. Or maybe they don't feel like they deserve recovery or they don't deserve to be happy. We need to help them in counseling work through these things. Mood issues must be addressed to prevent relapse. Remember that relapse begins when thoughts or urges or behaviors return to the addicted mindset. So when they start having the negative thinking, when they start feeling more paranoid, when they start feeling a sense of over entitlement, when they start hanging out with people who used to use or just neglecting their own physical health, that is the beginning of relapse for most people. Addictive behaviors were learned as a way to stop some sort of distress. And we can go spend an hour going down that rabbit hole. People don't just wake up one morning and go, hey, I want to screw up my life, let me start abusing crack cocaine. That's just, it's not what people do. They chose that behavior. They chose that chose to start using drugs or continue to using drug. Continue using drugs for a reason. And you know, it may be just because their brain chemicals are, are so out of balance now that when they start to sober up, the cravings and the withdrawals are so bad that they use in order to quote, feel normal. It could be that they're self medicating mood disorders or other psychiatric disorders. There's a lot of reasons could be their self medicating physical pain. We need to understand the function of the addictive behaviors. Learned behaviors cannot be unlearned. Okay, I'll say that again. Learned behaviors cannot be unlearned. That's why relapse is such a problem problem sometimes because people have learned that hey, you know, when things get really Bad. If I use this drug, if I do this, it numbs the pain for a minute. It gives me some respit. And when things get really, really bad, sometimes that pops out again. Sometimes the brain says, okay, nothing else is working. Remember back when I had a patient that I had worked with over the years who had multiple relapses and. But he finally got long term sobriety, 16 years of long term sobriety. And then life hit him with, you know, a double sucker punch and he relapsed. You know, life got completely overwhelming. And it's important to remember that those behaviors that we know that have been rewarding at some point in our life are always back there somewhere in the back of our mind. And they can be triggered if nothing else is working. Alternate behaviors and their consequences must be more rewarding than the addictive behavior and their consequences. And that's easy to say, hard to do. We need to recognize again what the behavior is communicating to us, what function it's serving. Is it numbing physical pain? Is it helping somebody sleep who has insomnia because their anxiety is so bad? Is it giving them a break from their oppressive depression? What is it doing? And then once we understand that, we can identify things that the person may try to do instead. Now people always say, well, you know, going on a run or doing, going to an amusement park isn't going to give me the same high as, you know, smoking a rock. Well, yeah, that's true. And in the short term, what you're doing may not be quite as rewarding as using the drug, but we want to help people also start looking towards long term, good, orderly direction in the big scheme of things. What is more rewarding, you know, immediate gratification right now and then weeks or months of misery because you have to detox and start over again and you may, you know, be abandoning family members or do you want to forego that immediate gratification and focus on things that are maybe less intensely rewarding, but they're rewarding and more fulfilling in the long term. Unfortunately, there is no pharmacotherapy for most drugs. Stimulants are, you know, one of those big areas like methamphetamine and cocaine and even, you know, your prescription stimulants like Adderall, there aren't medications to for medication assisted therapy for those people. However, some medications such as your norepinephrine, dopamine, reuptake inhibitors, your NDRIs like bupropion and naltrexone are currently being studied. NDRIs unfortunately though, bupropion, which a lot of people use for nicotine cessation, can be abused and overdose and diversion are areas of concern. Some people will chop up their bupropion and inject it. They will snort it. Um, it is. And, and since people get a prescription for it just like they do for sertraline or any of the other antidepressants, they do have a ready supply. NDRI also may not be able to be used by competitive athletes because it does increase the levels of norepinephrine and dopamine in the system, which help people feel more relaxed and more alert, which is why the athletes take it. It helps them feel like they've got a competitive edge. But that's one of those things that may pop up on a drug screen for competitive athletes. If you're working with somebody who has to be drug tested, you know, that's important to recognize. We need to remember what the function of drugs are. Stimulants help people. And a lot of times people who abuse stimulants are feel fatigued, feel depressed, feel run down, feel hopeless, feel helpless, you know, they feel blah. And the stimulants help pep them up. So, you know, when we're looking at somebody who's abusing stimulants, we're going to be also looking for underlying depressive issues that may be going on. Sometimes there's anxiety though, and they've gotten so revved up and so anxious for so long that they're kind of running out of gas and they're using the stimulants to help keep them going and push through hallucinogens like your psychedelics which act on the NER act on the serotonin receptor 5 HT2A. Just as a side note, create a state of empathetic well being. A lot of times people who use those types of psychedelics just want to feel chill. Dissociatives reduce glutamate, which is your main excitatory neurotransmitter, and can also alter pain. Dissociatives are depressants. And some of the more common dissociatives out there are ketamine, which people either get illegally or by prescription, or dextromethorphan, I.e. that cough syrup that's out there. And youth have found ways, and older people too, I guess, have found ways to abuse dextromethorphan in order to get high from it and then delirium. These reduce acetylcholine and some of the common over the Counter medications that are used to achieve this effect include Benadryl and Dramamine. We do, when we do our assessment for clients, we want to ask them all the medications they take with regularity and in what dose because they've found ways to abuse a lot of OTCs. Inhalants like glues and paints are typically depressants. If somebody is inhaling, you know, they might like the feeling of the euphoria and the relaxation. That's what they're looking for. Marijuana often increases dopamine. It's generally relaxing and can have some pain relieving properties, especially if it's high in the CBD component. Some people, when they take marijuana that is hot, has extra high THC levels will experience a lot of anxiety from it though I have yet to talk to anybody that feels like it energizes them. A lot of times it's either anxiety, anxiety or relaxation factors to consider when thinking about medication assisted therapy cost. Sometimes these things are covered under insurance, sometimes they're not. And it can get really pricey. I'm not sure what it is now, but back in the day of what, 10 years ago, Vivitrol by injection was really expensive. And a lot of our clients who were struggling with alcohol dependence wanted to get the Vivitrol injection and it just was out of their price range. Availability and accessibility. Are you going to have that in stock and how is easy is it for the person to get to it? When I was at the opioid treatment program, we were the only one within like 120 miles or something. People would drive an hour and a half one way every single day just for dosing and you know, that's not very available or accessible. Think about how much that cuts into their day. So they can't work as much or they can't work at all and how much it costs to drive there. And there are a lot of issues with it. We want to make sure that people have something that works into their relapse prevention and their recovery plan and helps them become empowered and financially stable and, you know, happy and healthy and all that stuff. We want to look at side effects. Sometimes the side effects are minor, like upset stomach, but as people age, the liver becomes less effective at or slower. What, however you want to say it at clearing toxins from the body. And it's important to look at whether drugs are particularly appropriate for people who are over 55 or for people who are under 24. And why under 24? Because the brain is still developing prior to the age of 24 that prefrontal cortex especially. And some of these medications may have a, an, an impact on the brain development. Now most of the studies that I read seem to indicate that it was the lesser of two evils. We're talking about harm reduction here. Exposure to heroin repeatedly or you know, some of those other drugs repeatedly was much harder on brain development than was a steady controlled amount of a certain medication. That's going to be between the patient and their doctor. Barriers to drugs, workplace drug testing. If somebody is working, for example, in a DOT sensitive position, they are not going to be able to take methadone. That's, or opioids in general. Any, any of your opioid treatment medications in general. Now some of your other medications like the bupropion may be available. Now why do I keep coming back to bupropion? Bupropion increases norepinephrine and dopamine. Most drugs increase norepinephrine and dopamine. So it is a drug that kind of partially activates some of those. Some of, well, it doesn't activate the receptors, it keeps the neurotransmitter in the synapse for longer, but it makes those neurochemicals more abundant in the person's brain. So bupropion can help take the edge off for a lot of people. Some medications do not play well with the medication assisted therapy drugs and you know, a doctor will know whether there is a contraindication and most people when they are incarcerated are not going to be able to access and, or afford medication assisted therapy. So if somebody is getting ready to go to jail, it's probably not a good idea to start them on medication assisted therapy unless you know that they'll be able to continue it once they are incarcerated. And motivation is another thing to consider. We don't want to. Well, it's ideal to not prescribe medication assisted therapy to somebody who just wants to take a pill every day and poof, magically they don't want to use anymore. You know, it doesn't work that way. They need to address the reasons that they used, they need to address any co occurring biopsychosocial issues. So if they're not motivated to, to engage in the process and if they're not motivated to stay clean, that's going to be a problem. A lot of these medications you cannot combine with alcohol or benzodiazepines, your anti anxiety medications because it can be deadly. And that's a, that's a big issue. If somebody is not motivated to agree to Stay completely clean and sober. It can be very dangerous for them. Stigmatization is another barrier for a lot of people. And there's a lot of science that supports medication assisted therapy. If you go to SAMHSA's website, if you go to any of the resources that are in the class, you'll see the research that shows that the outcomes typically are a fair amount better for people who are maintained for at least a year on medication assisted therapy. The dogma out there is that people are replacing one drug for another. And you know, I want to think about it for a second. Yeah, you've got people that are taking illicit drugs or are having to, you know, get drugs from somewhere, buy them off the street, mix over the counter medications with prescriptions, whatever they're doing that is very uncontrolled and can be very dangerous. And they can get high if they are motivated for recovery and they agree not to do those things. The medications that they're taking for medication assisted therapy are going to hopefully take the edge off in, in most cases, but they're not going to get high. They may have a sense of calm. That's those neurotransmitters reacting a little bit. Evidence based treatment is medication assisted therapy is evidence based treatment. They've done the studies, they've shown that the outcomes are much better. 12 step groups for a long time would not accept people who were on medication assisted therapy. However, a lot of them are becoming much more progressive. And methadone anonymous is an alternative for people who are on opioid medication assisted therapy like Suboxone or, or methadone. Counselors have different experiences and biases. A lot of times counselors only know what they've heard kind of in the break room. They haven't gone in and really done a lot of reading on the benefits and the drawbacks to medication assisted therapy. And so it's important to educate yourself. Even if you're not working with people that have opioid addiction, which is highly unlikely because most people are working with a few people who have that. But even if you're working with people, for example, who have alcohol dependence issues, you know, they may be on medication assisted therapy, we need to know what the options are for them. Ant abuse doesn't work for everybody, which is why Vivitrol gained so much popularity at a certain point. But we'll get there. And most payers require medication assisted therapy to be considered when available. However, not all payers will reimburse for it. So you need to know what the different payers Whether it's Medicaid, Medicare, state funding, private insurance, you know, what will that organization actually compensate for? Duration of most pharmacotherapy is not indefinite. It is, as I said earlier, months to years. The white paper from SAMHSA said that for opioid addiction, for example, the minimum amount of time is usually a year, but the maximum is two years. They really want people to be solid in their recovery before they start titrating goal. The goal is ultimately stabilization, but each person needs flexibility. If you have somebody who is addicted to opioids and alcohol, also has bipolar disorder and, you know, has multiple other psychosocial stressors, they will probably have a much different treatment program than someone who is addicted to opioids and has a really supportive home and work environment. Smoking cessation. Let's just talk about that one real quick. A lot of our clients smoke, and it's important to recognize that nicotine is a gateway drug. Let's face it, nicotine messes with the brain chemistry. And when nicotine isn't enough, that's when people start thinking, you know, I need a little bit more, because just having a cigarette or smoking a cigar ain't cutting it. Smoking cessation is recommended to be a part of each. Any recovery program in order to help people get off of those mood altering substances and quit relying on mood altering substances to help them cope with distress. The nicotine replacement therapies come in patches, gums, lozenges, and even nasal spray. You know, it's available, it is out there. A lot of them can be purchased at places like Sam's Club and Costco and probably even Walmart. You don't need a prescription for a lot of these. Some people look towards antidepressants like bupropion in order to help them cope. And that obviously is by prescription, as well as varenicline, which is a partial agonist, which means it stimulates some of those nicotinic receptors a little bit. It turns them up just a little, but not, you know, full on, which can take the edge off cravings for a lot of people until their brain chemistry rebalances and they stop having those cravings. For alcohol dependence, there is ant abuse. I tried to figure out how to say that and I practiced it, but I'm not getting it right now. Ant abuse. Most of us know what that is. You take it. People have a very violent physiological reaction usually when they drink. If they've taken ant abuse, that's because when they drink, their body doesn't process the alcohol the same way and it actually builds up to toxic levels really fast. Camprol or acamprosate and naltrexone are also options for treating alcohol dependence. Antabuse blocks acetyl to acetyl to Hyde Dydrosinase. I can't talk today. The reaction is flushing, palpitations, chest tightness, nausea, headache and anxiety. Most people don't want to feel that. So when they take ant abuse it helps them avoid slips or relapses. Because it is much more punishing to drink than it is to not drink. Unfortunately, it does affect the liver even without alcohol. And motivation is necessary. A lot of clients who are put on it, especially if they're not really motivated for treatment, are going to experiment to see how much they can drink before they actually get to sick. Camprol is another option that's out there and it typically doesn't have any drug interactions. It has minimal side effects except for diarrhea. It reduces the symptoms of protracted withdrawal from alcohol. And this is important. It really helps reduce those symptoms of insomnia, anxiety and restlessness. Super important. Unfortunately, in patients who have suicidal ideation it can increase suicidality. If somebody has a lot of anxiety, is really restless. This can be helpful as long as they're not suicidal. Maintenance pharmacotherapy for opioids usually uses long acting medications in a controlled setting with the addition of counseling and social services. Long acting medications, they get into your system and they last like 24 hours. You're not having that peak and valley that high and low that you get when you're taking illicit medications. The benefits is that it helps avoid withdrawal and cravings. It has been shown over and over again to reduce the transmission of diseases because people aren't shooting up anymore and reduce crime because they're not having to steal to get steal to get the drugs or money for the drugs. And it can be useful in the detoxification phase to make detox a little bit less painful. But it can also be useful in a maintenance situation for that year to two years while the person's brain and body are recovering and they're developing and getting solidified in their new skills and their new recovery lifestyle. Methadone is basically opioid substitution therapy. It is targeted for harm reduction. People are put on methadone because it is something that the doctor can control and it reduces some of the the injecting of of opioids. It typically when people are going to opioid treatment programs they have to take of care part in counseling. So that's beneficial to the individual. It's highly regular regulated and opioid treatment programs have to be licensed by samhsa, the Substance Abuse and Mental Health Services Administration. Methadone is a mu opioid agonist, which means it turns on those mu opioid receptors which help with people with pain and produce a feeling of euphoria. Typically it doesn't have significant or it allows people to not have significant withdrawal symptoms or cravings if the dose is right. And getting that initial dose right can take a little bit of monkeying. But the goal is to keep people from having that wicked flu like reaction that they have when they detox off of opioids cold turkey. In opioid treatment programs, patients are regularly drug tested and generally there is a zero tolerance policy for use of any other non approved medications. And as I said, treatment programs are required to provide a certain amount of counseling and psychosocial services. The phases and this is defined in the Code of Federal Regulations, Part 42. This isn't something we just pulled out of the air. There are very specific phases that people go through. There are no take homes of methadone for the first 30 days. So people have to show up every single day to get dosed. After 30, 30 days, they're eligible for one take home per week for the next three months. They are eligible for two take homes per week from day 91 through day 180 provided that they've had negative drug screens. If they have a positive drug screen, they they reset to phase one. They're eligible for three take homes a week with no more than two days at any one time for day 181 through one year. Still having to have negative drug screens. After one year they can get four take homes per week with no more than a two day supply at any one time. Again, negative drug screens after two years in treatment eligible, they're eligible for five take homes per week with no more than a three day supply at any one time. And if somebody is in treatment for longer than that, then they may get up to six take homes per week. But as I said earlier, the goal is generally to get people titrated off of the methadone within two years. Beneficial effects of opioid treatment programs Enhanced recovery reduced mortality. There's a 70% reduction in overdose, trauma, homicide and medical illnesses. That includes any of your bloodborne pathogens and those sorts of things. So think about how that's beneficial not only for the individual, but for society, how much money society saves. If you want to think of it from a purely economic standpoint, improved health of the individual both medically and psychiatrically, which helps them be able to become more independent, more empowered, more financially stable and improved psychosocial functioning. Employment is generally a requirement of opioid treatment program participation. Lack of criminal activity is a requirement. And a lot of times when people are feeling better, they're more able to engage and complete their family responsibilities. Does methadone get you high? Because of its longer half life, methadone suppresses withdrawal and drug and drug cravings for 24 to 36 hours at prescription doses. There is no real euphoria, which is why they have those limits on how many concurrent take home doses any person can have. It does cause sedation, which can be reassuring for some people because opioids typically are sedating. So they may get a feeling something like they used to get when they were getting high, but not nearly as intense, unfortunately, because it works on those mu opioid receptors, it can be deadly if it's mixed with benzodiazepines or alcohol. Both of those are depressants. You combine them with methadone, you can have severe bradycardia, you can have people stop breathing. There's a lot of problems. So it's essential that people who are on opioid replacement therapy are also aware that they cannot under any circumstances use benzodiazepines or alcohol. Cognitive impairment may occur during the initial induction phase because they're trying to get the dosage right when there's a change in dose or when it's combined with any other drugs or medications. And this can be prescribed drugs or medications on a stable dose. Once the person is, you know, getting the same dose every single day, the patient develops a tolerance to it so they can drive safely, complete complex tasks and care for others. Buprenorphine is an alternative to methadone for opioid addiction. It is a long acting opioid agonist antagonist. You can only get so much of a euphoric feeling off of buprenorphine. It has what they call a ceiling effect. So when people are taking buprenorphine, you know, they, they may get a certain amount, but it then they can take more of it. It's not going to help them feel any better. They reach that ceiling. Multiple forms of buprenorphine are available. Generally suboxone is combined is buprenorphine plus naloxone. That's the most common because it prevents more. It's better at preventing diversion than Subutex which is buprenorphine only. And bupren X is also A form of buprenorphine that's used for treatment of acute pain. Buprenorphine binds to the opioid receptors in the body. It only activates the receptor around 40%, not 100% like heroin or methadone. If the person is already in withdrawal, then activating those receptors, 40% is going to really take the edge off and they're going to feel a lot better. You know, not high, but they're going to feel better. They're not going to feel like crap. If they're not in withdrawal, dropping from 100% to 40%, they are going to have some withdrawal symptoms. It's important to recognize that, you know, there's not a middle ground in there. With buprenorphine, they can't make it. So 80% activation, then step it down like they can with methadone. With buprenorphine, it's 40%. There is a very low risk of overdose, but again, people can OD on it if they combine it with benzodiazepines. Buprenorphine is less restricted than methadone, as you've probably seen. There are buprenorphine clinics that have popped up all over the place. Methadone clinics or outpatient treatment programs. Our opioid treatment programs, I'm sorry, are becoming very few and far between. Buprenorphine is a Schedule 3 drug where people can get a prescription from the pharma pharmacy with refills for up to six months. They can get buprenorphine from outpatient physicians as. As needed. Addiction counseling, unfortunately, is separate and patients may be referred to another provider for this service or in some cases may not be referred at all. Unfortunately, the rules for this are a lot different than they are for methadone, which is one thing that really bothers me, but I didn't write the laws. The treatment efficacy of methadone and buprenorphine are evidently equivalent. They have similar opioid side effects. The abuse potential is slightly higher for buprenorphine, but not a lot higher because, remember, it has that ceiling effect. Buprenorphine has fewer drug interactions. It's more convenient because you can get it. It's much more accessible, and it's not age restricted. You can use buprenorphine in people under the age of 24. Methadone, however, is less expensive and doesn't have that nasty little sealing effect. Depending on your client, how much they're using, you know, what their situation is. All of those factors are going to have to go into making a decision about whether somebody should be considering methadone or buprenorphine. Suboxone combines buprenorphine with naloxone. Don't confuse it with Subutex which is buprenorphine only. The short term desirable effects of Suboxone include pain relieving. That's between 20 and 30 times more powerful than morphine. Wow. You know, just think about that for a second. Some people experience a mild euphoria that can last for around eight hours with general effects of the substance lasting for up to 72 hours. So there's a fair amount of pain relief that can go along with this. Some people having a sense of calm and inflated well being, a perception of fewer worries and lower stress and increased relaxation. All of these are happening because of that 40% activation of those neurotransmitters. But it is a much more mild than what they got when they were using Suboxone may be abused by individuals addicted to a short acting opioid like heroin by using it in between doses to keep withdrawal symptoms from occurring. So if they were using heroin, for example, some people who are on Suboxone may take their dose and then take a little bit of heroin just to prevent the withdrawal symptoms. And that's not okay. The naloxone part of the, of the Suboxone only kicks in if the Suboxone is altered and injected or snorted. Basically the goal was to prevent that rapid access euphoria. Suboxone is dosed such that that the prescriber is or prescribe is getting enough to avoid withdrawal symptoms as much as possible, as much as they can with only a 40% activation. In a person who's not already tolerant to opioids to the effect of Suboxone can cause a mellow high. Exposure to naloxone is lower with sublingual versus buccal administration. So if you want to reduce the exposure to the naloxone then they should put it under their tongue. If you want to make sure they have the full effect, they need to put it between their gum and cheek like any other opioid tolerance develops quickly and goes away quickly. That's really important. This is why we see one of the reasons we see so many overdoses, because people will detox and you know, try to try to find recovery and then they will relapse. But they go back to the dose that they were using when they stopped. And unfortunately the body has already started to recover. So that dose is way too freaking strong now. And that is what can put people, you know, in a, in a bad place. There's a danger of overdose in patients who have tapered or stopped using opiate. Opiate agonists who relapse. It is important to know that narcon, which the opiate reversal, we all know about, narcon now, that is naloxone and can be purchased without a prescription at all major pharmacy chains. If you have opioids in your house, it is ideal to also have Narcan in your house. And when both of my parents, when they were in hospice care at home, we had a crap ton of opioids and miscellaneous meds around the house from hospice. And in a situation where there was somebody who was addicted, I could see how that could get diverted. So if you're living with somebody who is, you know, taking as prescribed high doses of opioids on a regular basis for chronic pain, you know, it is ideal to have Narcan in the house, not necessarily so much for them if they're, you know, not addicted, but they're using it as prescribed. But for anybody else who might get ahold of the opioids, long term pharmacotherapy is available and effective for several addictions. Medication plus counseling has been shown to be much more effective at helping people achieve sustained recovery than either one independently. When it comes to smoking, Nicotine replacement is available over the counter and bupropion or varenicline are available by providing by prescription to help with the cravings. Multiple medications are also available by prescription for alcohol dependence. We don't, again, don't want people to think that the whole goal is to rely on this drug to keep them clean and sober. They need to address what's causing their cravings, they need to address their triggers, they need to address their underlying issues. Medication assisted therapy is a medium term intervention to help people have the energy and the focus and the ability to participate in treatment if they otherwise can't. Methadone, buprenorphine maintenance have been proven to reduce mortality, crime and the spread of infection. The substitution therapy, you know, substituting something that is less harmful helps eliminate withdrawal cravings and heroin effects. One client that I worked with, I remember, specifically refused to detox from opioids unless he could do it with medication assisted therapy. He was not willing to detox if he was going to have to feel the full bore of the withdrawal symptoms, which is something to think about if you've got a client who says, okay, I'll detox. But under these conditions it might be something to negotiate. And any of these medications need to be individualized in their Dosing in order to make sure that it does the job, but it doesn't cause the person to get high. Does impairment change if significant life change change, such as major weight loss, anxiety or change in family situations, Major life changes, you know, that is just, that's going to affect the mood of the person, maybe put them more at risk for relapse, but it's not going to change the dosing. Now, weight loss and dehydration both could potentially alter the levels of the drug in the person's system. So that is an important factor to consider. I know, you know, some of the people who used to come to our opioid treatment program worked outside all day long and that was an important issue to monitor was the level of the opioids in their system as well as obviously when, when anxiety, family changes, those sorts, sorts of things increase. People are at much greater risk of relapse, period. Which means they may be more tempted maybe not to use opioids again, but to start smoking or using alcohol or something else. And we know that that can lead down a very, a very slippery slope very quickly. Are there any questions? I'm really excited. In a couple of weeks, we've got another presentation on medication assisted therapy. And I did a whole bunch of research and they've done some really interesting studies. The recommendations actually have changed for working with pregnant women, for example. So, you know, I've got a lot of new cool stuff to share with you on that one, and that's during recovery month. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand ceus for this podcast is at allce.com/podcastce. That's allce. Com podcastce. 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