Examples of opioids are: Painkillers such as; morphine, methadone, Buprenorphine, hydrocodone, and oxycodone. Heroin is also an opioid and is illegal.
Opioid drugs sold under brand names include: OxyContin®, Percocet®, Palladone® (taken off the market 7/2005), Vicodin®, Percodan®, Tylox® and Demerol® among others.
Drugs that are not opioids are; cocaine, marijuana, methamphetamines, ecstasy, LSD, GHB, Ketamine, other club drugs, or steroids.
To understand fully you must be aware of the difference between tolerance, physical dependence, and addiction:
As a person takes opioids for an extended period of time, they become less sensitive to it and require more to achieve the same effect. Receptors in the brain become less sensitive. This means they need more and more opioid to achieve the same effect. This is called tolerance. When the body can no longer make enough natural opioids to satisfy the less sensitive receptors, the body becomes dependent on the external source. This is physical dependence.
“Physical Dependence” is a physiological state of adaptation to a substance, the absence of which produces symptoms and signs of withdrawal. It is possible to be physically dependent on a drug without being addicted to it. Physical dependence is the result of physical changes in the brain. It is not a matter of willpower rather it is actual physiology.
Addiction is defined as a behavioral syndrome characterized by the repeated, compulsive seeking (psychological dependence) or use of a substance despite adverse social, psychological, and/or physical consequences, along with the physical need for an increased amount of a substance as time goes on to achieve the same desired effect. Addiction is often (but not always, as with an addiction to gambling) accompanied by tolerance, physical dependence, and withdrawal syndrome.
People are dependent on water and food but are not addicted to them. If a cancer patient is taking large doses of painkillers, he/she will become tolerant and physically dependent on them (meaning they will experience withdrawal symptoms if the drug is abruptly removed) but they are not necessarily addicted to it (meaning they will not seek out the drug despite adverse consequences once the drug is no longer needed for pain).
Addiction is a disorder that requires treatment while physical dependence is not. This is important to understand in order to be able to discern between switching one addiction for another and treatment.
The American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine, recognizes these definitions below as the current accepted definitions.
Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.
Addiction is uncontrollable compulsive behavior caused by alterations of parts of the brain from repeated exposure to high euphoric responses.
Withdrawal syndrome consists of a predictable group of signs and symptoms resulting from abrupt removal of, or a rapid decrease in the regular dosage of, a psychoactive substance. The syndrome is often characterized by over activity of the physiological functions that were suppressed by the drug and/or depression of the functions that were stimulated by the drug. In other words, opposite of what the drug did. If the drug suppressed depression then the person would be depressed while in withdrawal. If the substance suppressed pain then the person will experience pain while in withdrawal.
Withdrawal from opioids can be severe and excruciating. Withdrawal generally begins between 4 to 72 hours after the last opioid use (depending on dose and opioid), The symptoms are both physical and emotional and include: dilated pupils, goose bumps, watery eyes, runny nose, yawning, loss of appetite, tremors, panic, chills, nausea, vomiting, muscle cramps, insomnia, stomach cramps, diarrhea, shaking, chills or profuse sweating, depression, irritability, jitters, and increased sensitivity to pain.
Withdrawal is a symptom of brain adaptations caused by some substances. As someone takes more and more of an opioid they increase their tolerance and require more and more to achieve the same effect. The level of tolerance where the body can no longer naturally compensate for the absence of the substance is called physical dependence. Withdrawal is a symptom of physical dependence. If you are not physically dependent on a substance you will not experience withdrawal from it. To achieve a comfortable transition off a medication you have become physically dependent on requires matching your taper off of the drug with your brain’s ability to adapt to each decrease. Too fast will cause discomfort.
No- with successful buprenorphine treatment, the compulsive behavior, the loss of control of drug use, the constant cravings, and all of the other hallmarks of addiction vanish. When all signs and symptoms of the disease of addiction vanish, we call that remission, not switching addictions.
The key to understanding this is knowing the difference between physical dependence and addiction.
Buprenorphine will maintain some of the preexisting physical dependence, but that is easily managed medically and eventually resolved with a slow taper off of the buprenorphine when the patient is ready. Physical dependence, unlike addiction, is not a dangerous medical condition that requires treatment. Addiction is damaging and life-threatening, while physical dependence is an inconvenience, and is normal physiology for anyone taking large doses of opioids for an extended period of time.
It is essential to understand the definition of addiction and know how it differs from physical dependence or tolerance.
The American Academy of Pain Medicine (AAPM), American Pain Society (APS), American Society of Addiction Medicine (ASAM), and (NAABT) National Alliance of Advocates of Buprenorphine Treatment, have recognizes these definitions below.
Physical dependence and tolerance are normal physiology. Addiction is a disorder that is damaging and requires treatment.
When a patient switches from an addictive opioid to successful buprenorphine treatment, the addictive behavior often stops. In part due to buprenorphine’s long duration of action, patients do not have physical cravings prior to taking their daily dose. The drug seeking behavior ends. Patients; regain control over drug use, compulsive use ends, they are no longer using despite harm, and many patients report no cravings. Thus all of the hallmarks of addiction disappear with successful buprenorphine treatment.
Therefore, one is not trading one addiction for another addiction. They have traded a life threatening situation (addiction) for a daily inconvenience of needing to take a medication (physical dependence), as some would a vitamin. Yes the physical dependence to opioids still remains, but that is vast improvement over addiction, is not life threatening, and it can easily be managed medically. It’s also important to note that the physical dependence pre-existed the buprenorphine treatment and was not caused by it.
Addiction is a brain disease that affects behavior. This addictive behavior can be devastating to the patient and their loved ones. It’s not the need to take a medication that is the problem, many people need to take a medication, but rather it is the compulsive addictive behavior to keep taking it despite doing harm to one’s self or loved ones that needs to stop. Whether or not the person takes a medication to help achieve this shouldn’t matter to anyone. If a medication helps stop the damaging addictive behavior, then that is successful treatment and not switching one addiction for another.
It is best to SLOWLY reduce your therapeutic dose of Methadone to 30 mg a day or less for at least a week, before discontinuing it completely for at least 36 hours before starting Buprenorphine. You MUST be in mild to moderate withdrawal before you take your first dose of Buprenorphine. If you are doing well in Methadone treatment it may not be advisable to change treatments at all unless you and your doctor determine it is in your best interest.
It is VERY important to follow these guidelines and prevent precipitated withdrawal.
Physical connections create pathways in the brain that can be altered when we learn something new. These changes to the brain can be seen with medical imagery. With long term difficult things like learning to play a musical instrument, these changes can be permanent. Addiction is a learned behavior that changes the brain as well. The brain becomes conditioned to want the substance. Through counseling and other behavioral modification we can actually, in some cases, change the brain physically. By changing our environment, starting a new job, new hobbies and friends, all will alter our brain in some way. It is possible to undo some of the changes that occurred while addicted. Therapy will recondition the brain closer to pre-addiction status. This will better prepare the patient for a time when they may no longer require medication.
Medication alone can reduce cravings and withdrawal, but recovering from an addictive disorder requires a rewiring of the brain and medication alone is not enough. Attention to eliminating things in life that cause stress or depression will help minimize the chance of relapse. Disassociating with friends who are in active addiction can be difficult but very necessary. An experienced counselor/therapist will be able to teach other techniques that will further help undo some of the brain changes and conditioned learning that occurred while becoming and once addicted.
It is important to find a counselor/therapist that is skilled in treating patients that employ medications in their treatment. Some counselors still dismiss the science behind addiction medicine because they may have been able to successfully end their addiction without it. They sometimes zealously focus on the singular approach that helped them and as a result may not be providing the best care for an individual who may require medication. It pays to find a counselor with a modern evidence-based philosophy of addiction treatment.
Counseling/therapy helps the patient rebuild relationships, repair finances, get a job, assume family responsibilities, decrease stress, anxiety and depression, and helps the patient make other meaningful changes in their lives that will allow them to achieve and maintain addiction remission.
The simple answer is yes. When you are dealing with an opioid addiction, individuals are treading a fine line with incarceration, institutions or even death in some cases. When you start your buprenorphine program, you may start feeling “like your old self”. You will start to curb your cravings for opioids, start feeling better physically and mentally and your confidence will also start to rise. With this new confidence, some patients get a false sense that they have their main problem (opioids) under control and think they are capable of doing a lesser addictive drug recreationally. This is a huge mistake. Eventually, old habits will take over and you may find yourself back using and this could lead to relapse. At Right Path Clinics, you will be required to submit regular drug screens and positive test results can lead to discharge from our program.
Per current guidelines, we see clients weekly for the first month. (This is important to closely monitor your response and compliance to the treatment, adjust medications, and observe for any unforeseen side effects.) After the first month of your treatment our goal is to start seeing you bi-weekly, and eventually monthly if you demonstrate that you are stable on your dose of buprenorphine and confidence in you abstinence from opioids. All treatment plans are personally tailored to each individual patient and your visits will ultimately be at the discretion of your doctor and councilors.
You will still be able to be treated for pain associated with elective dental and surgical procedures or accidents. Ideally, your doctors should speak with each other about the plan. Frequently your non-Right Path doctor will offer you a plan that needs to be reviewed by your right path doctor so you will not run into a problem with compliance with Right Path. Our doctors are committed to minimizing your pain and will provide you with a clear, safe and sensible plan that will not risk your recovery and will effectively deal with your pain. Incorrect and risky use of pain medicines frequently started our patient’s issues with narcotics and we take this responsibility very seriously. Our aim is to deal with your acute pain completely, safely and sensibly.
It is recommended to take the first day of treatment off. Some are able to work even on Day One. Certainly after Day One, you should be able to work with greater attentiveness and clarity than before starting treatment. The transition from addictive substance to Buprenorphine is usually painless and most patients experience no adverse physical effects. In fact most say that they feel normal again, like they were never on drugs at all.
Confidentiality of Alcohol and Drug Dependence Patient Records (summary)
The confidentiality of alcohol and drug dependence patient records maintained by a practice/program are protected by federal law and regulations. Generally, the practice/program may not say to a person outside the practice/program that a patient attends the practice/program, or disclose any information identifying a patient as being alcohol or drug dependent unless:
Violation of the federal law and regulations by a practice/program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/program or against any person who works for the practice/program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.
Buprenorphine is an opioid medication used to treat opioid addiction in the privacy of a physician’s office.1 Buprenorphine can be dispensed for take home use, by prescription. This, in addition to buprenorphine’s pharmacological and safety profile, makes it an attractive treatment for patients addicted to opioids.
Buprenorphine is different from other opioids in that it is a partial opioid agonist. This property of buprenorphine may allow for;
At the appropriate dose buprenorphine treatment may:
* When compared with full opioid agonists (such as oxycodone and heroin)
Buprenorphine is an opioid partial agonist. This means that, although Buprenorphine is an opioid, and thus can produce typical opioid effects and side effects such as euphoria and respiratory depression, its maximal effects are less than those of full agonists like heroin and methadone. At low doses Buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms. The agonist effects of Buprenorphine increase linearly with increasing doses of the drug until it reaches a plateau and no longer continues to increase with further increases in dosage. This is called the “ceiling effect.” Thus, Buprenorphine carries a lower risk of abuse, addiction, and side effects compared to full opioid agonists. In fact, Buprenorphine can actually block the effects of full opioid agonists and can precipitate withdrawal symptoms if administered to an opioid-addicted individual while a full agonist is in the bloodstream. This is the result of the high affinity Buprenorphine has to the opioid receptors. The affinity refers to the strength of attraction and likelihood of a substance to bind with the opioid receptors. Buprenorphine has a higher affinity than other opioids and as such will compete for the receptor and win. It will “knock off” other opioids and occupy that receptor blocking other opioids from attaching to it. If there is enough Buprenorphine to knock the opioids off the receptors but not enough to occupy and satisfy the receptors, withdrawal symptoms can occur; in which case the treatment is more Buprenorphine until withdrawal symptoms disappear.
Suboxone, contains both buprenorphine and the opiate antagonist naloxone. Naloxone has been added to Suboxone to guard against intravenous abuse of buprenorphine by individuals physically dependent on other opiates. If misused by injection, the naloxone (along with the buprenorphine itself) will help cause immediate withdrawal in opioid dependent people, however when taken sublingually, as indicated, the naloxone is clinically insignificant.
Buprenorphine has to be specifically tested for and still isn’t commonly included on standard drug screen panels. Buprenorphine will NOT cause a positive result on tests for other opiates. The typical urine tests used to detect methadone, oxycodone, heroin, and other opioids check for a different metabolite than that found with buprenorphine and will not show a positive result in buprenorphine (only) maintained patients.
Headache is one of the most commonly reported buprenorphine side effects. A common remedy for headaches is aspirin or other OTC (over the counter) pain remedies with a glass of water; but water alone may be all that’s needed. Medications, including laxatives and all opioids, can contribute to dehydration; and one of the first symptoms of dehydration is a headache. Just by staying hydrated throughout the day may be enough to solve the headache side effect, and reduce some of the other side effects as well.
Be mindful there are other things that can cause headaches such as caffeine and nicotine withdrawals. Drinking plenty of water is the easiest first step in trying to figure out the cause of headaches. But if the headaches persist, consult with a medical professional to be on the safe side.
Many medications can cause constipation, including opioids, and especially long-acting opioids. Fast-acting, short-duration opioids, such as heroin and hydrocodone, cycle through periods of great effect to periods of lesser effect. It is during those periods of lesser effect that the body is able to produce bowel movements. However, long-acting opioids, such as buprenorphine, methadone and time-released oxycodone, have a continuous influence on the body without the period of lesser effect that would allow for bowel movements. This can lead to chronic constipation if preventative strategies aren’t employed.
Constipation can become serious, and, in extreme cases, require surgery, but for most, it’s an unnecessary inconvenience and discomfort. Fortunately, it is usually avoidable with OTC remedies, exercise, good diet and good hydration.
If drinking more water along with a high fiber diet and increased exercise isn’t enough, stool softeners such as docusate sodium (brand name Colace®) which comes in soft gel tablets are an option. This product softens stools and has a lubricating effect, but is not a laxative. Polyethylene glycol 3350 (brand name Miralax®) is a powder that dissolves into drinks and both softens stools and increases the frequency of bowel movements. It works by drawing water into the colon, and for that reason drink plenty of water to avoid dehydration – a contributor to constipation. According to an informal survey conducted online, either one or a combination of both has been effective at relieving most buprenorphine-induced constipation. Avoid harsh laxatives if possible; and, of course, consult your doctor before using any of the remedies mentioned here.
This may seem like an innocuous symptom and is not often cited as a buprenorphine side effect, but it can be very serious and very costly.
Saliva is the mouth’s primary defense against tooth decay, gun disease, and maintains the health of the soft and hard tissues in the mouth. Saliva washes away food and other debris, neutralizes acids produced by bacteria in the mouth and provides disease-fighting substances throughout the mouth.
With dry mouth (which is a side effect from all opioids) these benefits are diminished which allows bacteria to multiply and often leads to gingivitis which can lead to periodontitis disease, and eventually bone and tooth loss. -more-
Most insurance companies cover the medication itself. However many people choose to pay for it themselves to keep their condition private. There are some doctors that will only take cash. It is one of the many unfair aspects of this disease. It pays to shop around. A doctor can choose what if any insurance they will accept (in some states). All of the Right Path Clinics proudly take insurance as well as self-pay (cash or debit) clients that do not have insurance. We have been told by most of our patients that our fees are typically lower that other providers and some claim we are twice as affordable. You can always give us a call to see if your insurance carrier is accepted.
In the United States most physicians in private practice are for-profit businesses. Our free enterprise system allows them to charge what they feel the market will allow, and it is up to the individual physicians to accept or not accept private insurance. If you do have insurance, many companies will allow you to submit the claim yourself for direct reimbursement. If your plan covers behavioral health conditions demand they pay your claim. Some insurance companies still feel that they can discriminate against people with addictive disorders. Most states have laws requiring insurance plans to cover addiction treatment.
Although there is the potential for addiction to buprenorphine, the risk is low. Few people develop the dangerous uncontrollable compulsion to buprenorphine that we know as addiction. Buprenorphine will maintain some of a patient’s existing physical dependence to opioids but that is manageable and can be resolved with a gradual taper once the patient is ready.
Amazingly despite 100% of people being treated for addiction with buprenorphine have demonstrated that they have a greater vulnerability to opioid addiction than the average person, very few become addicted to the buprenorphine, meaning very few lose control of their medication intake, nor experience uncontrollable compulsions and cravings toward the buprenorphine.
People can become addicted to anything that causes pleasure; consider gambling, sex, food, and internet. There is even a condition where patients drink so much water they dilute their blood, causing some level of intoxication (hyponatremia). They are addicted to this behavior, although water is not considered addictive. Substances and activities all have some potential addiction liability. Many factors including genetics and environment contribute to someone’s potential of becoming addicted
The brain has a natural reward system that helps us to learn that things that cause pleasure are good and should be repeated. This helps our species survive by reinforcing the desire for food and sex. These activities initiate a biochemical sequence and release dopamine in the brain. This feels good and is reinforced when repeated. Some substances can trick the brain and initiate the same biochemical sequence, but to a greater and unnatural degree. The brain senses this activity as the most pleasurable and hence the most necessary for survival, and creates a memory of the activity and cravings for more. The cycle reinforces itself and can lead to addiction (uncontrollable dangerous compulsive behavior)
Research has shown that substances that reach the brain faster have a higher potential for addiction. Also substances that provide a stronger effect cause more reinforcement. This begins a cycle of euphoria then craving then euphoria, craving and so on. Each time the cycle completes it reinforces a memory in the brain, the more frequent the cycle the more reinforcing.
The potential for addiction has to do with 3 main things, the speed of the onset, the level of reinforcement (pleasure), and the duration of action. IV heroin, is fast acting, strong euphoria, short duration. This gives it a high potential for addiction. Drugs with short intense cycles provide more potential for addiction than drugs with long “flatter” cycles.
Buprenorphine has a slow onset, mild effect, and long duration, which puts it at some risk of being addictive, more than water, but less than full agonist opioids, like heroin, morphine, oxycodone, and hydrocodone.
In countries where only Subutex is available (buprenorphine without the naloxone safeguard added), some people have injected their buprenorphine, thus decreasing the onset time and increasing euphoria, this in turn increased the potential for addiction and thus more people became addicted to it. The risk of addiction is less when taken sublingually as directed.
If you miss a dose and remember it hours later, take it upon remembering. If you forget until it is close to the time of the next day’s dose, do not take a double dose. Not because you will take too much but rather you will just be wasting it, due to the ceiling effect. After being on treatment for a relatively short period of time you will feel so normal it may be difficult to remember unless you tie taking your medication to an activity you do every day at the same time. For example, after you have coffee or orange juice in the morning, or while reading the newspaper.