Treating patients with opioid or alcohol use disorders is a specialized area of medicine that is not well understood. Unfortunately, the lack of standardized treatment and limited knowledge of the neurobiology of addiction (a disorder that impacts core biological instincts of survival) has kept treatment outside the realm of medicine. Attempts to help addicts are undoubtedly well intentioned, but despite lofty goals, patients often continue their downward spirals – even under the best medical supervision. It is critical to effectively treat the withdrawal symptoms medically. Alcohol withdrawal may require using drugs like benzodiazepines for a short period of time. Once the alcohol detox is completed, patients can be started on one of three medications approved by the FDA in conjunction with behavioral counseling to prevent relapse. Patients impacted by opioids can be detoxed and/or maintained on FDA approved opioids like methadone and buprenorphine (better known by the brand name Suboxone).
The present opioid epidemic has taken a frightening turn for the worse with increased quantities of heroin and an even more powerful opioid called fentanyl coming into the country. This is unprecedented, and we have no experience dealing with this situation.
The preferred mode of treatment in this country is residential/inpatient programs. Many addicts also end up in prison. There is a misconception that the stint in rehab will do the trick and patient will not go back to using opioids. Forced abstinence, also called conditioned abstinence places the patient at a very high risk of relapsing and overdosing when he/she returns home to a familiar landscape of past drug use. Treatment centers must develop strategies to prevent relapses.
The psyche of an addict who seeks, or has recently completed rehab, is precariously positioned at best and highly vulnerable to the triggers that cause relapse. Unfortunately, many treatment facilities provide in-patient programs that range from thirty to ninety days, which experts agree is woefully inadequate to deal with the physical, emotional and psychological damage incurred by extended drug use. Patients who are properly detoxed and receiving treatment cannot access illicit narcotics and are in supportive environments, devoid of the stimuli that drive their drug abuse. Doubtless, these facilities are critical in kick-starting sobriety, but the (generally) brief stays that are provided may result in the recovering addict being discharged with an overestimation of his/her ability to maintain the new lifestyle.
Unfortunately, when the patient is released, the conditioned abstinence that was enforced in the therapeutic setting is no longer in effect and relapse is all but certain. Because the addict generally returns to the environment that prompted the initial use, the cycle starts over; the brain has been affected and he/she is not far enough removed from the sensations that were experienced on the drug. The wanting system of the brain has been hijacked and, when tempted, is more likely than not, to give in to the siren song of the drug.
Methadone and Suboxone have been discussed at length in this series with experts both promoting and decrying their use. Those who support these regimens argue that harm reduction is an appropriate method to treat drug abuse. Opponents point out that using opioids to treat opioid use disorders is merely creating dependence to another addictive drug. While these drugs are the go-to for many, there is another option that is often overlooked in the prevention of relapse – particularly for patients returning home from residential treatment or incarceration.
Naltrexone was synthesized in 1965 and developed as non-opioid medication to protect detoxed heroin addicts from relapsing when they returned home from residential treatment or incarceration. It belongs to a different class of drugs called opioid antagonists. It is very similar to the opioid reversal drug naloxone (Narcan). It works by binding to opioid receptors and blocking their effects, thereby interrupting the cycle of addiction. If the person taking it uses the problem drug simultaneously, it blocks the rewarding effects of the substance.
Naltrexone’s use as a medication-assisted therapy is also appealing because it is procured with a prescription and has limited side effects. Another attractive feature is that it cannot be diverted and used incorrectly. People who are interested in using naltrexone to overcome addiction must be highly motivated and adhere to the protocol for using it. If the pill is not taken specifically as directed, the cravings and effects of the drug will persist. That being said, cravings can also serve a useful purpose. Those who experience them may be more motivated to engage in treatment. It is often the patients who feel like they are fine and have things under control who return to abusing drugs.
Naltrexone was approved by the FDA for the treatment of opioid addiction in 1984 and for the treatment of alcoholism in 1994. The medication is available as a daily pill or as a monthly injection marketed under the brand name Vivitrol. This is often the better option because a single dose of Vivitrol works for approximately one month, which removes the issue of adherence that the pill requires. That being said, it must be part of a broader treatment plan that includes cognitive behavioral therapy, twelve-step programs, counseling and lifestyle changes. Contributing factors such as trauma and abuse need to be addressed as well. Naltrexone is not a cure for addiction, but it can help facilitate a setting in which treatment can be more effective. Experts recommend a course of six to twelve months so that all seasonal triggers can be experienced through the eyes of sobriety.
Before starting on naltrexone, patients must be detoxed off of all legal and illegal opioids for seven to ten days. This withdrawal should be medically managed by someone who is well versed in the process, and who possesses comprehensive knowledge about addiction. This drug can negatively affect the liver, so careful monitoring is critical.
Self-help groups have traditionally eschewed medication-assisted therapies because they use drugs to help people maintain abstinence. There is also the possibility that the addict may use larger amounts of illicit drugs to overcome the effects caused by them – sometimes with fatal results. Supporters of these treatments counter that harm reduction is preferable to death, and believe that people who are early in their dependency might benefit from a limited course of this drug.
Naltrexone and other medication-assisted therapies cannot replace recovery programs, but should be considered in some cases. As with treatment for any illness, there is no “one size fits all.” There are many paths to success and people who are struggling with substance use disorders need options, support and reliable and effective medical intervention.
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