FAQ’s About Addiction Treatment

Being addicted to opioids is not the same thing as being addicted to other substances like cocaine or alcohol. I have taken care of those with different types of addictions for decades and the difference is obvious. There is a high spontaneous recovery found with addictions other than opioids, where the majority of people just quit on their own and a low level of spontaneous recovery in opioid addiction. Patients in treatment will tell me on a regular basis of how they got off other substances by themselves with success and without prolonged sickness but despite multiple trials, failed to successfully get off opioids. Statistics show that 90% of those who undergo “detox” for opioid addiction and then receive no medication assisted treatment relapse within one year of treatment. This is in general regardless if they get 3 or 30 days of in patient detox. Simply put, clinics like ours do not exist for treatment of other substances because they do not have the same long-term physical effects on the body in the way opioids do. Medically assisted therapy helps relieve this sickness and the cravings that go along with it, giving patients a higher success rate.

There are many goals in treatment, not just abstinence. The fact is that on their own, abstinence-based treatments have no proven benefits in the treatment of those addicted to opioids. Even those in the field of addiction treatment often do not understand that they cannot assume what may help people with dependence to one substance helps those addicted to another. The basis that the only real goal must be complete and total abstinence has its roots in 12-step therapy, which identifies those with addiction as having spiritual, emotional, and personality defects. These can only be dealt with by 12-step philosophy and abstinence from alcohol. There is debate as to the actual benefit of such an approach over any other form of treatment in alcohol dependence. There is no doubt that some individuals have found help from a 12-step approach but no evidence that it improves recovery by itself in opioid addiction. An additional problem lies in the inconsistent opinions of those who participate in 12-step recovery if it’s permissible to use medication that alters mood or consciousness.

This is usually made in the form of a statement or rhetorical question. This both casts moral judgment on anything but total abstinence as morally wrong and weakness of the addict and makes a very ignorant comparison between drugs that produce very different outcomes when taken. One cannot swallow any antibiotic with the expectation that the outcome will be the same or eat any mushroom one finds in the yard or supermarket with the expectation of the same outcome. Such comparisons between Buprenorphine and opioids like Heroin or Oxycontin demonstrate an ignorance of the basic pharmacology of Buprenorphine and its safety profile. If total abstinence from all medication can be achieved without a loss of function at work, in healthy relationships, self care and pursuit of ones happiness and good health then that is the goal but the goal of treatment is to help patients achieve those goals by any medical and philosophical means needed.

How much Buprenorphine a person takes is directly related to the level and potency of opioids they use prior to starting treatment. The more opioid used the more Buprenorphine it takes to get withdrawal under control. New laws in Ohio prohibit doctors from prescribing more than 16mg of Buprenorphine per day unless they are Board Certified in Addiction Medicine. Although the FDA has approved doses up to 32mg per day there is little evidence that doses over 16mg on a chronic basis have any effect do to the “ceiling effect” of the drug. This means that at 16mg per day one reaches saturation of the vast majority of the bodies opioid receptors and little happens when doses above 16mg are taken. Over time many people do well on smaller and smaller doses. There is no agreed upon optimal length of treatment. Some doctors only use Buprenorphine in acute detox for a few weeks. Others in the field of Addiction argue that those with lengthy histories of opioid addiction should never come off medication do to the high risk of relapse. At the clinic each patient works with their doctor to determine what is best for them. For those who wish to taper off medication and are stable, this is done slowly so they can adjust usually after 12-24 months of treatment. Factors that predict difficulty in full taper include long periods of daily opioid use prior to treatment, IV Heroin use, chronic pain or psychiatric problems such as depression and anxiety.

Standard of care is to see persons taking Buprenorphine no less than every 30 days. If patients are not doing well they are seen more frequently either by their own doctor or the Medical Director. There is no additional charge for these appointments other than $25 for additional urine tox screens performed in the clinic if a person relapses. Clinic patients also must agree to present within 24 hrs when called in for a random tox or pill counts.

“Despite the fact that studies have not shown improved outcomes for patients who are in Buprenorphine programs who attend behavioral therapy vs. those who just see their doctor and get minimal drug counseling the State of Ohio has established new rules that require patients to participate in Behavioral Therapy for at least the first year of treatment with Buprenorphine. If they are stable and remain on medication after a year they can be relieved of this mandate if permitted by their treating Dr. If there is some issue that prohibits a person from attending such therapy they can go to 12 step meetings 3 times a week alternatively. These are requirements made by the state of Ohio.”

It is important to remember to interpret all research in the area of addiction and psychiatry with caution. The research on the effects of Behavioral Therapy on those in Buprenorphine programs was done on primarily heroin users only. It measured only the amount of urine screens free of illicit opioids. There was no measurement of return to work or the benefit to ones emotional stability or relationships. When we look at recovery we look at these areas as part of measuring success. Not just if the person is abstaining from opioids. The goal of therapy should be to assist one in repairing the harm that comes to all of these critical aspects of a persons life. As was mentioned before 50% of people who take medication for opioid dependence fail in the program. This is not a physiologic problem but a psychological one and to succeed one must address these problems while on medication.

Like most things in life you get out of it what you put into it. We at the Restorative Health Clinic are strong believers in the power of many forms of therapy to assist patinets in this process whether they be 12-step, Rational Recovery, Smart Recovery or some other form of therapy that focuses on helping those with addiction get their lives back in order. The most important variable in outcome is patient choice. Your doctor will help you choose what approach is best for you.

In general yes. New Ohio law prohibits patients from taking medications like Stimulants or Sedatives for more than 12 continuous weeks unless they have written permission from a doctor who is Board Certified in Addiction Medicine. Myself and Dr. Korala who are both board certified psychiatrists at the clinic and are ASAM board eligible plan on completing the certification exam in October 2015.