I must admit I was a little surprised earlier this week when Bridget Walsh, our Clinical Case Manager and I screened a former patient who wanted to return to The Coleman Network for Addiction Medicine for a second detox off opioids.
How Relapse Can Happen
People relapse for many reasons. Sometimes it’s caused by a surgery-planned or otherwise—that puts them back on pain medication; sometimes it’s being in the wrong place at the wrong time without the right coping skills for the situation.
Neil fell into this category.
Screening someone who has completed an Accelerated Opioid Detox and has relapsed is important for us so we can figure out the next move to help this person obtain long-term sobriety.
Neil came to us for a detox off street heroin which turned out to be laced with fentanyl. Before heroin, Neil had become addicted to pain medication. His doctor was prescribing some of the medication; Neil was also supplementing the meds with pills he purchased.
He had heard about our five-day program for short acting opioids in an outpatient setting. This worked well for him; he didn’t miss a lot of work and his girlfriend of several years, was available to be with him. At the completion, Neil got the naltrexone implant which blocks the opioid receptors for nearly eight weeks. Neil was grateful. He was looking forward to a life not driven by chasing dope.
Three Important Differences Between Suboxone and Naltrexone
1. Suboxone and other buprenorphine products create physical dependence, naltrexone does not.
Suboxone contains both buprenorphine and naloxone. This means buprenorphine produces effects like euphoria at moderate doses, but these are weaker than full opioid agonists like heroin or methadone. When taking buprenorphine for an extended period of time, someone will become physically dependent on it and will experience withdrawal symptoms when they stop. Suboxone is not necessarily the wrong choice. When taken intended, buprenorphine is safe. It can also help dampen the effects of physical dependency to short acting opioids. In case of overdose, Buprenorphine can increase a safe outcome.
As naltrexone is a pure blocking agent, it does not create physical dependence or tolerance. Occupying the opioid receptors, Naltrexone blocks other opioids from having a place to ‘land’. Before starting naltrexone therapy, a patient must be made aware that their body will also be losing its tolerance to opioids during this period. Relapsing after having detoxed and not having used opioids for a long time results in a higher risk of having a fatal overdose. There are different forms of Medication Assisted Treatment (MAT) that may be right for different people.
2. Suboxone (and other opioids) must be completely out of your system before starting on naltrexone therapy.
When given too close to a person’s last dose of short acting opioids, both buprenorphine and naltrexone, can cause precipitated withdrawal. This means a person takes a substance that pushes opioids off the receptors abruptly.
Our program is one of the few in the country that can get people safely and comfortably onto naltrexone. Many choose naltrexone over Suboxone so that they don’t become dependent on another opioid. However, we strongly support the use of Suboxone in the right scenario. We can carefully ‘bump’ the existing opioids off the receptors as we move to naltrexone. This process length varies depending on what is being eliminated.
3. Suboxone is a controlled substance, naltrexone is not
Buprenorphine users on Suboxone (or Bunavail, Zubsolv and Cassipa) in treatment must find an expert who has a special DEA waiver. This medication is highly controlled and patients receiving it must comply with guidelines, restrictions and protocols. Most programs require patients to have weekly to bi-weekly appointments. Patients taking Suboxone must comply with random pill/film counts, regular and random urine drug testing, and should be aware of the consequences of losing these medications or requesting early refills. These measures are in place to protect the patient and the provider, but it also creates complexity to using Suboxone to treat an addiction to opioids. Buprenorphine products are not supposed to be prescribed to people who are also taking benzodiazepines.
On the other hand, Naltrexone does not require a special license. A prescription for naltrexone does not show up on a state’s Prescription Monitoring Program. Any doctor is allowed to offer this medication. We typically use long-acting naltrexone as an insert placed under the skin in the abdominal area. This will allow the opioid receptors to ‘bathe’ for close to eight weeks. The Coleman Network for Addiction Medicine has specialized in using naltrexone therapy for over 25 years.
How The Colman Network for Addiction Medicine Can Help with Opioid Use Disorder
If you are seeking help for yourself or a loved one, please give our Care Advocates a call at 888-705-9615. They can direct you to one of our medical providers to help you wade through the choices; it can be daunting and confusing, especially when the stakes are so high. Deciding to stop using opioids requires some knowledge of what each of the choices for Medication Assisted Treatment (MAT) entails. Research shows that MAT is extremely important in increasing the odds of long-term success for a person with Opioid Use Disorder.
Joan Shepherd, FNP