Joseph B Stringer, MA, LPC, CAP, MAC
The media are all awash in the current opioid epidemic. Throughout our country people are dying due to opioid overdoses. This seems to be the result of several issues. Number one is that many so-called “dealer/distributors” are cutting their opioid products with anything from other opioid medications to drain cleaner. Another issue is that some people have had previous experience with opioid use, then went through the detoxification/withdrawal process and have been clean. Going back to using again, many people mistakenly believe that they can just pick up where they left off. What these people don’t understand, is that the body has been off this drug long enough that re-introducing this drug after detox cannot begin with the same amount and strength as before – the body is learning about this foreign substance again; therefore, overdose and often death accompany this situation.
Let’s look at the various opioids, how they affect the body and how they come to be dangerous.
In an article written by Doctors Kosten and George in “Addiction Science and Clinical Practice in July of 2002, they state that, “Opioid tolerance, dependence and addiction are all manifestations of brain changes resulting from chronic opioid abuse. The opioid abuser’s struggle for recovery is in great part of a struggle to overcome the effects of these changes. Medications such as: methadone, LAAM*, buprenorphine and naltrexone act on the same brain structures (and receptor sites) and processes as addictive opiates, but with protective or normalizing effects. Despite the effectiveness of medications, they must be used in conjunction with appropriate psychosocial treatments.” This means individual counseling therapy with a professional, licensed clinician or addiction specialist. I mention to patients that just doing one without the other only gets you half way to recovery. Using both on the other hand, provide a complete treatment.
In treating opioid abuse, the focus of treatment is on the patient rather than his/her disease. A clinician’s understanding of neurobiology of dependence a d addiction is invaluable to the patient’s treatment and recovery. Identifying realistic expectations of the patient is a key to successful treatment, methods and goals. Additionally, informed patients of brain origins of addiction can also benefit from understanding that the illness they have has a biological basis and doesn’t mean that the patient(s) are bad, weak or undisciplined.
Tolerance and/or dependence occurs when the brain cells that have opioid receptors on them gradually become less responsive to the opioid stimulation, requiring more of the opioid in order to achieve the same effects. When I worked in a Methadone Clinic in Ft. Collins, CO, we had a poster on the wall that said, “When you want to stop using, but your brain won’t let you…”. Amazing what one can learn from a poster!
Once the brain gets used to a substance, it wants it more and more, creating a “brain struggle” as it now begins to go through Opioid withdrawal and unpleasant withdrawal symptoms. By the way, these symptoms include restlessness, nausea, vomiting, diarrhea, shortness of breath, drowsiness (the “nods”), runny nose (rhinitis), irritability, and even death!
The parts of the brain that struggles with the opioid withdrawal include the “locus coeruleus” or the LC and the mesolimbic reward system. The LC produces a chemical called noradrenaline that sends its chemical signal to the part of the brain (brain stem) that stimulates wakefulness, breathing, blood pressure, and alertness among other functions. Basically, when these functions are suppressed, the patient begins to experience drowsiness, slowed respiration, low blood pressure (common effects of opioid intoxication). No wonder that extensive use of opioids leads to unconsciousness, lethargy and death!
THE PHARMACOLOGICAL INTERVENTIONS AND TREATMENT OF OPIOID ADDICTION
If anything you’ve read so far sounds familiar to you or a friend, it’s time to think about treating this addiction so it does not go any farther. I say this so that you can get on top of this. Many people who prolonged their treatment options for too long are no longer with us. Don’t be that person! When a person over-doses on opioids and make it to the ER while they are still alive, the ER physician/staff administer NARCAN, a drug used for emergencies that will take the patient out of their “horror-show” withdrawals. The goal is to get to the ER BEFORE one goes into cardiac arrest….
There are several treatment options open for a patient who is experiencing the symptoms consistent with serious withdrawal or dependence/addiction. Here are a few of the options:
Naltrexone – (known as Vivitrol, ReVia) is medication is used in the ER (NARCAN) to assist with detoxification and relapse. It impacts the mu receptor site in the brain and keeps other opioids from attaching to the opioid receptors, so addictive opioids cannot attach to these receptors. Another benefit is that Naltrexone attaches to the receptor sites 100 times more strongly than regular opioids do, essentially blocking opioids from any chance of attaching and essentially blocks the feeling of pleasure that one would get from other opioids. In order to begin this medication, patients must be completely detoxified from ALL opioid medications, including methadone.
Suboxone - it is actually a combination of two drugs nalaxone and buprenorphine. As a partial opioid agonist, buprenorphine’s job is to deliver very diminished opioid doses to a patient who is addicted to a stronger opioid. It provides a way for the client to be gradually weaned off their pre-existing addiction, while minimizing the opioid withdrawal symptoms that would come from the process. The other drug in Suboxone is naloxone, a pure opioid antagonist. An agonist excites an opioid receptor; an antagonist shuts it down blocking agonists from reaching the receptor and even reversing the effect of opioid agonists already in the patient’s system by intercepting the signals that the receptors send to the nervous system.
Buprenorphine – It, too reacts to the mu receptors. It has two different effects. One, a low dose of this medication has a similar effect as methadone, while at higher doses behaves as naltrexone.
Methadone – This is one of the synthetic opioids that are long lasting, unlike morphine, heroin and other opioid drugs that remain in the system for a short time. Because methadone has a steadier, long acting influence on mu receptors, it relieves cravings, urges, and compulsive drug use. Some people who enter methadone maintenance programs believe they can still use heroin or other opioids and get high. Methadone is blocking those receptors in the brain and the only thing that can happen to someone determined on still getting high will just…GET DEAD due to an overdose!
LAAM – This medication is a longer acting cousin of methadone, in fact, it is a derivative of methadone (see, there is a genetic- family resemblance!). A patient that opts for LAAM can receive it three times per week. The main concern with this drug comes from recent concerns about heart rhythm problems (it is very limited in use in the US, due to FDA’s 2001 warnings).
While these medications may sounds like a cure all, they work best when combined with individual counseling and therapuetic groups.
Pingora Behavioral Health currently has funding to help offset the cost of these medications.
Please contact us at (307) 463.0337 to discuss your options.
*These sublingually administered formulations of the partial opioid agonist buprenorphine were the first medications for opioid dependence since methadone and LAAM.
#Opioids exert their pharmacological actions through three opioid receptors, mu, delta and kappa whose genes have been cloned (Oprm, Oprd1 and Oprk1, respectively). Opioid receptors in the brain are activated by a family of endogenous peptides which are released by neurons.