Treating Opiate Addiction

opiate addiction treatmentTreating opiate addiction is difficult. Detox alone is insufficient for most opiate addicts. After getting opiates out of the body, you’re left with the 90% of the problem. After detox, there’s what’s called Post-Acute Withdrawals. This is an excerpt from Addictions and

There are two stages of withdrawal. The first stage is the acute stage, which usually lasts at most a few weeks. During this stage, you may experience physical withdrawal symptoms. But every drug is different, and every person is different.

The second stage of withdrawal is called the Post Acute Withdrawal Syndrome (PAWS). During this stage you’ll have fewer physical symptoms, but more emotional and psychological withdrawal symptoms.

Post-acute withdrawal occurs because your brain chemistry is gradually returning to normal. As your brain improves the levels of your brain chemicals fluctuate as they approach the new equilibrium causing post-acute withdrawal symptoms.

Most people experience some post-acute withdrawal symptoms. Whereas in the acute stage of withdrawal every person is different, in post-acute withdrawal most people have the same symptoms.

The Symptoms of Post-Acute Withdrawal

The most common post-acute withdrawal symptoms are:

  • Mood swings
  • Anxiety
  • Irritability
  • Tiredness
  • Variable energy
  • Low enthusiasm
  • Variable concentration
  • Disturbed sleep

Post-acute withdrawal feels like a rollercoaster of symptoms. In the beginning, your symptoms will change minute to minute and hour to hour. Later as you recover further they will disappear for a few weeks or months only to return again. As you continue to recover the good stretches will get longer and longer. But the bad periods of post-acute withdrawal can be just as intense and last just as long.

Each post-acute withdrawal episode usually last for a few days. Once you’ve been in recovery for a while, you will find that each post-acute withdrawal episode usually lasts for a few days. There is no obvious trigger for most episodes. You will wake up one day feeling irritable and have low energy. If you hang on for just a few days, it will lift just as quickly as it started. After a while you’ll develop confidence that you can get through post-acute withdrawal, because you’ll know that each episode is time limited.

Post-acute withdrawal usually lasts for 2 years. This is one of the most important things you need to remember. If you’re up for the challenge you can get though this. But if you think that post-acute withdrawal will only last for a few months, then you’ll get caught off guard, and when you’re disappointed you’re more likely to relapse. (Reference:

The reason most people think treatment doesn’t work is because they consider detox and short-term counseling to be treating opiate addiction — it’s not. For treatment to work it should be comprehensive and long term. In reality, a recovering addict is always “treating” the condition, because a recovering addict can go back to the drug at any time after any length of time. Just like the diabetic never becomes un-diabetic, the recovering addict never becomes un-addict.

Heroin Laced With Fentanyl

Heroin laced with FentanylWhile heroin is a commonly known drug, you might’ve heard lately about heroin laced with Fentanyl, yet not know much or anything about Fentanyl. Here is a description:

Fentanyl is a synthetic opioid, meaning it is made in a laboratory but acts on the same receptors in the brain that painkillers, like oxycodone or morphine, and heroin, do. Fentanyl, however, is far more powerful. It’s 50-100 times stronger than heroin or morphine, meaning even a small dosage can be deadly.

Fentanyl can be produced in illegal laboratories, which means, for the foreseeable future, availability won’t decrease through government regulation. This synthetic opioid is very, very powerful, so it makes a dangerous drug like heroin much more dangerous and deadly. It only takes a small amount of Fentanyl to increase the effects of heroin and cause overdose. Even scarier, some drug dealers are selling a combination of heroin, Fentanyl and cocaine.

Those who buy heroin on the street and start using heroin laced with Fentanyl are at a much higher risk of overdose and death — the drug user becomes dependent on how much Fentanyl is used, their tolerance and other physical factors that in combination can create overdose. It sounds perverted, but a drug dealer might increase business if someone overdoses and dies from heroin laced with Fentanyl, because, on the street, the word of a powerful heroin/Fentanyl mix will likely create a buzz of interest as users seek greater highs. In the experienced user’s mind, they’ll think they can handle the more powerful mixture and that those who died were neophytes.

As congress begins decreasing the amounts of opioids doctors can prescribe, a certain number of patients who’ve become addicted to opioids, but need the drug for management of chronic pain, will seek drugs from alternative sources – if they begin buying synthetic opioids on the black market, this will increase the number of deaths, not lower the number of deaths. I don’t think drug addiction will respond to regulation — it can be treated, though. Heroin laced with Fentanyl is nothing to play with. The entire opiate/opioid addiction epidemic will only get worse until society decides to take action to find fundamental solutions.

Easier, Softer Way

easier, softer wayIn Chapter 5 of the book Alcoholics Anonymous there’s a warning about alcoholics seeking an easier, softer way to deal with alcoholism. Often someone suffering from addiction will seek help through a friend, a pastor, their doctor, a family member or maybe an individual therapist. I won’t say that any of these forms of help can’t work. I do know that addiction treatment is usually required if there’s to be much lasting change at all. The tough decisions and commitment necessary to deal with a medical condition as powerful as addiction are not easy. Some people deal with the problem through non-professional methods, but most people who suffer from addiction require some level of specialized addiction treatment.

The mistake most people make when trying to help someone who’s addicted to alcohol or some other drug is to immediately assign psychological reasons for the constant drinking or use of drugs: She had a bad childhood – He lost his wife – She has never fit in. In addiction treatment, we deal with the medical condition first. Addiction is a medical condition, a chronic brain disease, with a strong genetic influence that’s complicated by social and psychological factors.

Treatment begins by stabilizing the medical condition — detoxification, medical assessment, and understanding the chronic brain disease. Medication might be needed for detox, but the ideal course of action is to become drug free as soon as possible. When dealing with opiate addiction, Suboxone might be prescribed for the early period of treatment, long enough for the client to get into treatment and establish a support network. If the client can’t detox on an outpatient basis, inpatient detox will be recommended, and perhaps a few weeks of inpatient treatment.

Once there’s medical stabilization and we develop a treatment plan, then we begin dealing with the social and psychological aspects of addiction. Sometimes, a person is depressed and anxious in the beginning, but this is common for someone who’s been living a life torn apart by addiction. In some cases the depression and anxiety might have preceded the addiction, so that these co-occurring conditions are addressed and treated along with addiction. Depression and anxiety are not known to cause addiction, but they can co-exist with addiction, and addiction almost always makes co-existing conditions worse. So, when someone says that they’re drinking because they’re depressed, they don’t understand that alcohol is a depressant (although the first few drinks might have a stimulant effect) and makes depression worse over the long run, not better.

The life of addiction creates or masks problems that are dealt with if a person is to have the best chance at recovery. If a person stops drinking and nothing else changes, they’re usually filled with chaotic emotions, guilt, remorse, anxiety, depression, resentments, etc. These lingering consequences of addiction can overwhelm a person, making them restless and discontent, so much so they that go back to their drug of choice. If the person resolves the social and psychological problems, though, this doesn’t mean that he/she can return to social drinking or recreational drug use. Once biological predisposition to addiction is established, active addiction will recur once the person starts drinking or using again. Addiction is a chronic brain disease and so far there’s no known cure. If the person remains abstinent, however, they can lead a normal, fulfilling life. It’s not just people with addiction who are filled with chaotic emotions and psychological scars, but the person recovering from addiction has a chance and a need to deal with these problems and gain peace of mind — who wouldn’t benefit from taking time out to assess our emotions and psychological state?

So, if a person with an addiction problem tries to deal with the symptoms of addiction with symptomatic solutions, they might miss the fundamental nature of addiction which has to do with how the drug affects the brain. Many people who’re searching to find help, want help that will allow them to one day drink and use drugs socially with no consequences — the easier, softer way actually becomes very hard and painful. Ironically, (paradoxically?) it turns out that, for the addict, the easier, softer way is abstinence and recovery management.

More on Medication-Assisted Treatment

Post-acute withdrawal


The current misunderstanding around Suboxone as a medication-assisted treatment, MAT, for opiate addiction is confounding. Addiction treatment professionals, whether federally funded treatment providers or private treatment providers, who ban Suboxone from their treatment have much explaining to do.

Addiction treatment is complicated in many ways. The job of the addiction treatment professional, though, is to deal with addiction as it is, with all its complications, not as how it should be or we think it should be. There are many, many opiate addicts lost in a maze of drug use and visits to doctors and clinics that never seem to put them on the right path to recovery. The anti-Suboxone addiction treatment professional who sees an addict in this opiate addiction maze can insist the addict detox and maintain a totally drug free life, but this is not likely a realistic recovery plan.

For one thing, most insurance companies will not pay for expensive inpatient detox from opiates, even if the addict has insurance. If an opiate addict had a perfect situation in which they could spend 10 days or so in detox, then another 40 or so days in inpatient treatment, then in a halfway house situation for up to 6 months, perhaps the detox and drug free plan might work — but, even if this ideal treatment situation is possible, it all depends on the opiate addict staying in treatment, and the history of opiate addicts following through with such treatment after an initial full detox is not a history of success.

The problem with opiate addiction is that the withdrawal is difficult and the post-acute withdrawal is difficult, too. There are therapeutic strategies to help with post-acute withdrawal, like nutrition, exercise, support groups, etc., but it’s unprofessional in my opinion to deny the need for medication for some individuals, and especially with opiate addiction. Recovery from opiate addiction takes a long time — the brain has undergone damaging changes during addiction and the brain has to heal, and this takes time.

Suboxone is a drug that has allowed opiate addicts the time and comfort to get into treatment and stay in treatment without leaving because, whereas without the Suboxone, they feel so depressed and uninspired they just don’t care about recovery.

Addiction treatment professionals treat addiction, and addiction is complicated. Denying treatment to someone who is either taking Suboxone or seeking to take Suboxone just because there’s a bias against Suboxone flies in the face of all the evidence that Suboxone is a very effective MAT for many opiate addicts – denying therapeutic evidence that Suboxone enables recovery whereas before recovery was absent makes no sense in the realm of addiction treatment.

Opiate Addiction 2015


Opiate addiction

Unfortunately, statistics on opiate addiction and abuse are not current, but the American Society of Addiction Medicine, ASAM, has collected information from the most recent studies. What the information shows is disturbing. At NewDay Counseling, we see the reality of opiate addiction on a regular basis. When we decided to manage Suboxone clients, the decision was made not to get more people hooked on Suboxone, but to guide people through the withdrawal and recovery phase in order for the person to become drug free. Most people come to us already taking Suboxone. Too many people are taking Suboxone, then going back to Oxycodone or heroin, then back to Suboxone, seemingly with no end in sight. At NewDay Counseling we’re incorporating counseling, and group therapy if needed, in order to treat problems related to the chronic brain disease of addiction. We treat addiction, whether the addiction is to alcohol, cocaine, pot or opiates.

Opiate addiction is one of the most difficult addictions to treat. It’s very painful for a person to go through withdrawal from opiates without professional help. As a side note, even though opiate addiction is painful, unlike withdrawal from late stage alcohol addiction, it’s not life-threatening in and of itself. Methadone clinics are a testament to how difficult it is to treat opiate addiction — the clinics are basically a management of the addiction, not recovery from addiction. Suboxone is often a better alternative, but even Suboxone can be used as a maintenance drug and the person is not drug free, although Suboxone doesn’t produce the debilitating euphoric state of mind as opiates like heroin, morphine and Oxycontin produce, and the person taking Suboxone can take prescriptions home and not be chained to a regular visit to a clinic.

The goal of addiction treatment should be to become drug-free as soon as possible and to learn how to live well without drugs. Here is some information on opiates from ASAM:

National Opioid Overdose Epidemic

Over 100 Americans died from overdose deaths each day in 2013vi

46 Americans die each day from prescription opioid overdoses; two deaths an hour, 17,000 annuallyvii

While illicit opioid heroin poisonings increased by 12.4% from 1999 to 2002, the number of prescription opioid analgesic poisonings in the United States increased by 91.2% during that same time periodviii

Drug overdose was the leading cause of injury death in 2013, greater than car accidents and homicideix

About 8,200 Americans die annually from heroin overdosesx

About 75% of opioid addiction disease patients switch to heroin as a cheaper opioid sourcexi

In 2012, 259 million opioid pain medication prescriptions were written, enough for every adult in America to have a bottle of pillsxii

If a vulnerable group of Americans were killed at this rate annually by any other means, there would probably be a great outcry, but we hear next to nothing about this problem in media.

Medically-assisted treatment for opiate addiction


Medically-assisted treatment

As it stands right now there are restrictions on medically-assisted treatment for opiate addiction. Doctors who prescribe Suboxone and similar drugs are limited to a certain number of patients. There is legislation, though, presented by Sen. Edward Markey and Sen. Rand Paul to loosen these restrictions. Because heroin use is on the rise, this is needed regulation.

Suboxone along with counseling and addiction treatment has proved to be an effective treatment for opiate addiction. Opiate addiction is a serious healthcare problem, and in some communities opiate addicts have a difficult time finding a doctor to provide medically-assisted treatment because of restrictive regulations.

This is from Huff Post:

The legislation, known as the Recovery Enhancement for Addiction Treatment Act, would loosen restrictions on the number of patients a doctor could treat with buprenorphine for opioid addiction.

The consensus among the medical establishment is that medically assisted treatments such as buprenorphine (and methadone), along with counseling, represent the best chance for addicts to gain a foothold on sobriety. Both medications can make withdrawal less painful and can significantly diminish further cravings for opioids — greatly reducing the chance of relapse.

The Food and Drug Administration approved using buprenorphine to treat opioid addicts more than a decade ago. But federal regulations placed limits on how many patients a doctor could treat. After getting certified to prescribe buprenorphine, which is sold under the brand name Suboxone, doctors can only treat 30 patients at a time in the first year, and 100 the following year.

In areas hit hardest by the opioid epidemic, those limits have maxed out doctors and created lengthy waiting lists for prescriptions. The legislation would raise the first-year cap from 30 patients to 100 and allow qualified nurse practitioners and physician assistants to prescribe the medication. It also would give doctors the chance to remove the patient cap after one year.

Hopefully this legislation will pass. It’s very difficult to abuse Buprenorphine, and when someone tries they are easily caught. The small risk of abuse is worth taking for the huge benefit to opiate addicts wanting addiction treatment.

Signs and Symptoms of Opiate Addiction


Opiate addiction

In this post, I’m addressing only prescribed painkillers and addiction. I’ve dealt with other opiates like Heroin in other posts. What are the signs and symptoms physicians and others should look for to detect opiate addiction when a patient is taking painkillers over an extended period of time? Prescription painkiller use has skyrocketed since 2000. More physicians, healthcare workers, family members and concerned others need to understand the signs and symptoms of addiction in order to effectively with this problem.

When someone needs painkillers, it’s usually short term, so there’s no real problem, although physical dependence can happen to anyone. Physical dependence doesn’t equal addiction. A person can become physically dependent on an opiate, yet cooperate to get off the medicine and willingly seek long term pain management solutions that don’t cause physical dependence. Addiction is a chronic brain disease that develops in some people when they take opiates.

Here are some of the signs and symptoms of opiate addiction to look for with someone taking prescription painkillers – this is from the U.S. Dept of Health and Human Services:

1. Multiple episodes of “lost” or stolen prescriptions.
2. Repeatedly running out of medication early.
3. Aggressive complaints about the need for additional prescriptions.
4. Drug hoarding during periods of reduced symptoms.
5. Urgent calls or unscheduled visits.
6. Injecting opioids intended for oral use.
7. Using the opiates to achieve euphoric effects.
8. Unapproved use of prescribed opioid to self-medicate another problem, such as insomnia.
9. Frequently missing appointments unless opioid renewal is expected.
10. Unwilling to try non-opioid treatments.
11. Evidence of withdrawal symptoms visible at appointments.
12. Concurrent alcohol or illicit drug use.
13. Sedation, declining activity, sleep disturbances, or irritability unexplained by the pain or co-occurring conditions.
14. Deterioration of functioning at work, with family, or socially because of medication effects.
15. Forging prescriptions or obtaining prescriptions from nonmedical or multiple medical sources.



Opiate Addiction as Medical Concern

opiate addiction

Medical care and opiate addiction

If a physician has received training in addiction medicine, it’ll be easy for the doctor to speak with a patient concerning opioid addiction. Some medical professionals, though, find it difficult to talk about opiate addiction as medical concern because of the stigma and the perceived insult. Talking about addiction should be the same as talking about any other medical condition. Actually, doctors have great leverage as they come from a position of authority.

Not enough doctors are shooting straight with patients about addiction to pain killers and other prescription medicines that are often abused. Some doctors might not recognize the signs and symptoms and addiction.

If a physician or nurse suspect opiate addiction, they can confirm their suspicions by using DSM-5 Diagnostic Criteria for Opioid-Use-Disorder. If the patient shows a pattern of use described by at least two on the list of criteria, there is likely an addiction problem — here are a few:

A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.

Continued opioid use despite knowledge of having persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

Craving, or a strong desire or urge to use opioids.

When a physician suspects addiction and convinces the patient to detox from the opiates and seek treatment there’s a good chance the person will recover. If the problem is ignored, it will only get worse. Opiate addicts usually get caught trying to feed their addiction as they take more risks like going to multiple doctors or purchasing opiates from a drug dealer. Many times if the situation between doctor and patient is ignored it builds up until the doctor simply ends the doctor-patient relationship when the patient shows signs of desperation. It’s best to address addiction during the early stages, but this is when doctors are usually reluctant to intervene because they aren’t sure — maybe they only suspect there’s a problem and they don’t want to anger a patient who’s been coming to them for years and is respected in the community.

It can be difficult confronting someone who’s in denial, but if it’s done with care, concern and professionalism it will usually have the intended effect. Giving Suboxone to patients with an opiate addiction and calling it treatment is not enough — the person addicted to opiates needs addiction treatment that entails counseling, education and, most likely, group therapy and long-term recovery management. Addiction is a serious, chronic brain disease, and treating it otherwise is based only in opinion contrary to science and unexamined value-judgments regarding drug addicts that aren’t helpful. All medical professionals should know, in 2015, the facts regarding addiction and recovery.