With recent media coverage of the opioid epidemic, many people are first learning about opioid addiction. This past week, the opioid epidemic was declared a “Public Health Emergency”, bringing with it a call for more education. Learning about, and understanding drug abuse, is an important part of recovery. Those suffering from addiction, and their family members, need information about available treatment options.
At Livingwell Preventive Medicine, we support the use of Medication-Assisted Treatment (MAT) in addiction recovery.
The research is clear. MAT is more effective.
Many studies, including systematic reviews, have found that medication-assisted treatment can cut the all-cause mortality rate among addiction patients by half or more. That is a very significant impact! This is why the CDC, NIDA, and WHO recognize MAT’s importance.
MAT is the “gold standard” for opioid addiction treatment.
What is Medication-Assisted Treatment (MAT)?
Medication-Assisted Treatment (MAT) is the use of medications, in combination with counseling and other therapies, to provide a “whole-patient” approach to the treatment of substance use disorders.
MAT is primarily used for the treatment of opioid addiction (such as heroin and prescription painkillers), although it is also showing success in the treatment of alcohol abuse. The medication used for MAT works to bring the brain chemistry back to a ‘normal’ level. MAT can also prevent drug withdrawal, relieve drug cravings, and block the euphoria (“high”) from alcohol and opioids.
Research has shown that opioid abusers that attempt abstinence-based treatment (without medications) have a very high relapse rate, with more than 90% returning to opioid abuse within one year.
Medication assisted treatment gives those suffering from addiction the best chance at recovery.
Which medicines are used for MAT?
- Naloxone (Narcan)
- Naltrexone (ReVia, Vivitrol)
What are some emerging therapies in MAT?
- Low Dose Naltrexone (LDN)
- Medical Cannabis (Marijuana)
Buprenorphine is an opioid medication, that is FDA approved for treatment of opiate addiction, given in the privacy of a physician’s office. Buprenorphine can be prescribed for take home use by patients in an outpatient treatment program. This makes Buprenorphine different from methadone treatment, because methadone must be administered in a specialized clinic setting. Using Buprenorphine (Suboxone and other similar products) allows much better access for patients seeking opioid addiction treatment.
Buprenorphine/Naloxone are the active ingredients in Suboxone, Zubsolv, and Bunavail.
Buprenorphine is a “partial opioid agonist” which makes it different from other opioids (such as oxycodone, hydrocodone, Oxycontin, heroin).
Click here for a graphic/image to better understand how buprenorphine works.
The medication supports patients in recovery by allowing for:
Less cravings for opioids
Less euphoria (“high”) and less physical dependence
Relief from withdrawal symptoms
Reduced use of illicit opioids (like heroin)
Blocking the effects of other opioids
With successful buprenorphine (Suboxone) treatment, the addictive behavior often stops. Patients regain control over drug use and see an end to the constant cravings, compulsive behaviors, drug seeking, and loss of control.
Naloxone (Narcan) is a medication approved by the Food and Drug Administration (FDA) to prevent overdose by opioids such as heroin, morphine, and oxycodone.
Naloxone is a short acting drug which will bring a patient out of an opiate overdose by stripping the opiate from the opiate receptor and is a life saving drug.
Naloxone (Narcan) attaches to the same receptors in the brain as heroin and other opioids, and ‘boots them out’. It blocks the opioid receptors for 30-90 minutes, and reverses the respiratory depression that would otherwise lead to death from overdose.
The only effect of naloxone (Narcan) is to reverse the effect of opioids, it does not get you high. Naloxone does not have a risk for abuse and dependence.
Many communities are offering better access to Narcan in the face of the opioid epidemic. Some are also offering classes to educate the public on how to use Narcan to save lives. Contact your local public health department to learn more about available programs in your community. Boulder County offers free overdose prevention and Narcan training classes, and has several locations where Narcan is available.
Naltrexone (ReVia, Vivitrol)
Naltrexone is an opioid antagonist. Naltrexone blocks the euphoric (“high”) and sedative effects of opioid drugs (like heroin, morphine, oxycodone, etc). If a person relapses, naltrexone prevents the feeling of getting high. It is FDA approved for opioid dependence and alcohol dependence. Some reports show that naltrexone may reduce opioid cravings. There is no abuse or addiction potential with naltrexone.
Before starting naltrexone, patients must abstain from all opioids for a minimum of 7-10 days. You must have gone through detox and withdrawal from opioids, and have not used for 7-10 days, to safely start naltrexone treatment.
Naltrexone comes in a pill form or as an injectable. The pill form (ReVia, Depade) can be taken once daily. The injectable extended-release form of the drug (Vivitrol) is is given once per month. Naltrexone can be prescribed by any health care provider who is licensed to prescribe medications.
Vivitrol is an injectable, extended release form of Naltrexone, used to treat both alcohol and opioid addiction. If a patient uses opioids or alcohol while taking Vivitrol, they will not get high.
Vivitrol is given as a monthly injection, making it a much more convenient option for patients who have difficulty traveling to treatment programs on a regular basis. The extended release medicine helps patient compliance, as it does not have to be taken every day. Vivitrol is useful to help prevent relapse after detoxing from opioids. It offers an alternative approach to MAT than Buprenorphine (Suboxone) or Methadone. For some patients, Vivitrol can be used as a stepping stone in recovery, after transitioning off of Buprenorphine or Methadone.
Patients who have been treated with Vivitrol and naltrexone, have a reduced tolerance to opioids. This means that they are much more sensitive to the same or even lower doses of the opioids they used to take and/or abuse. If patients relapse after being clean for some time, they’re at a higher risk of overdose and death.
As with all medications used in MAT, naltrexone and Vivitrol are prescribed as part of a comprehensive, personalized treatment plan, that includes counseling and other therapies.
Low Dose Naltrexone (LDN)
Low Dose Naltrexone (LDN) is an off-label use of the FDA-approved naltrexone. The medicine is given in much smaller doses, a fraction of the strength used to treat alcohol and opioid addiction. A typical daily dose of LDN is between 1.5mg and 4.5mg, usually taken at bedtime. This is much less than the 50mg oral dose of naltrexone taken with ReVia.
LDN works by blocking the opioid receptors for just a few hours, rather than all-day blockade caused by the regular/higher dose naltrexone. These are the same receptors that the body’s natural endorphin system uses (endogenous opioid receptors). The response is for the body to dramatically increase its own endogenous (internal) endorphin production. The body continues to have higher levels of endorphins all day, even long after the LDN has stopped blocking the receptors.
Patients who have been taking opioids (prescription or not) for a long time, have depleted their body’s natural ability to produce endorphins (the body’s own naturally produced opioids). This causes a “low opioid tone” in the body. Many patients report prolonged withdrawal symptoms when stopping taking opioids, after taking them for long periods of time. These symptoms are due to the body’s low opioid tone. LDN has been found to be able to reverse this low opioid tone, and help boost the body’s natural ability to produce opioids. This plays an important role in many diseases, not just addiction recovery. LDN has been shown to reduce inflammation and boost the immune system. Doctors have been using LDN to treat a range of conditions including autoimmune diseases, Fibromyalgia, Multiple Sclerosis, Crohns Disease, HIV/AIDS, and many types of cancers.
Medical Cannabis (Marijuana)
There’s no question that cannabis is safer than opioids. Evidence is mounting to support use of cannabis in treatment of chronic pain. Likewise, experts are recommending cannabis be reviewed as an important player in the fight against the opioid epidemic. Research shows that cannabis plays an important role in helping patients decrease and even stop using prescription opioids.
In fact, studies show a reduction in opioid overdose deaths in states where medical marijuana is legal. In a study published in JAMA, researchers found that medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates. The mechanism for this is still not well understood, and further research is lacking, as marijuana remains a Schedule I substance.
Cannabis also treats the symptoms of opioid withdrawal. Cannabis, particularly cannabidiol (CBD), helps people tolerate withdrawal symptoms. It can treat nausea, vomiting, stomach cramping, restlessness, anxiety and insomnia, that are common in opioid withdrawal. Patients using cannabis experience less severe opioid withdrawal symptoms.
In addition to decreasing opioid use and opioid overdose deaths, and mitigating withdrawal symptoms, cannabis appears to improve retention in addiction treatment. Specifically, cannabis has been shown to improve retention in treatment with Naltrexone. A study done in 2009 showed that intermittent cannabis users stayed more than twice as long in treatment than abstinent users. The behavioral therapy in the treatment program was also shown to be more effective in the cannabis users than non-users.
When used appropriately, cannabis appears to play a potentially important role in addiction recovery. Ongoing research suggests that cannabis might have an effect on normalizing brain chemistry and function, although the mechanisms still need to be further elucidated. These brain changes help many patients exit the addictive thought cycle and welcome a new perspective.
For patients in recovery, or looking to enter addiction treatment, MAT should be strongly considered. Science supports the use of MAT. Regardless of the medication chosen for MAT, it must be used as part of a comprehensive addiction treatment plan, chosen according to the patient’s unique needs.
The use of MAT allows patients to have a chance to work on the other aspects of their addiction- lifestyle, social situation, psychological aspects and more. This enables patients to take back their life and control their own health and wellness.
Role for Cannabis in Treatment for Opioid Addiction? Medscape. Feb 06, 2017. https://www.medscape.com/viewarticle/875431
Bachhuber MA, et al. Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010. JAMA Intern Med. 2014;174(10):1668-1673. doi:10.1001/jamainternmed.2014.4005
Raby WN, et al. Intermittent marijuana use is associated with improved treatment retention in naltrexone treatment for opiate-dependence. Am J Addict, 2009 Jul-Aug.
Haroutounian S, et al. The Effect of Medicinal Cannabis on Pain and Quality of Life Outcomes in Chronic Pain: A Prospective Open-label Study. Clin J Pain, 2016 Feb 17.
Boehnke KF, et al. Medical Cannabis Use is Associated With Decreased Opiate Medication in a Retrospective Cross-Sectional Survey of Patients with Chronic Pain. J Pain, 2016 Jun
Lucas, Philippe, et al. Substituting cannabis for prescription drugs, alcohol and other substances among medical cannabis patients: The impact of contextual factors. Drug and Alcohol Review, 14 Sept 2015.