Replacement Therapy for Opiate Addiction

By Suzanne Kane

Kicking opiate addiction doesn’t have to be the painful and dreaded nightmare many addicts envision. There is replacement therapy that has been approved as an alternative treatment for opiate addiction.

What Constitutes Opiate Addiction?

First, however, it’s important to discuss what constitutes addiction to opiates. An individual can be addicted to numerous substances called opiates or opioids. In fact, opioids, commonly prescribed to treat pain, are one of three classes of drugs most commonly abused (the other two being central nervous system depressants and stimulants).

What are Opioids?

Opioids are analgesic medications – pain relievers – that, when taken as prescribed, are often effective in managing pain and rarely cause addiction. It’s when opioids are abused that addiction can occur, often in combination with other addictive drugs and/or alcohol.

Some of the compounds and brand names (in parentheses) within the opioids class are:

• Hydrocodone (Vicodin)

• Oxycodone (OxyContin)

• Morphine

• Fentanyl

• Codeine

• Propoxyphene (Darvon)

• Hydromorphone (Dilaudid)

• Meperidine (Demerol)

How Opioids are Abused

Abuse of the opioids includes snorting crushed powder from pills, taking pills orally, or injecting the medication. The National Institute on Drug Abuse (NIDA) says that injection and snorting have resulted in numerous overdose deaths, especially with the drug OxyContin, which was designed to be a slow-release medication. When an individual snorts or injects such medication, it causes an immediate release into the drug stream, resulting in exposure to high doses and potentially lethal overdose reactions.

But it’s the euphoric reaction that causes many users of opioids to become addicted. The opioids affect regions in the brain that mediate perception of pleasure. The resultant euphoria and/or sense of well-being that opioids users experience is a state that they want to return to again and again. Consistent and chronic abuse of opioids despite negative consequences leads to dependence or addiction to the substances.

What Happens When you Stop Taking Opiates

Even patients who are prescribed opiates for short-term management of pain may develop a physical dependence on them. This physical dependence, however, is not the same thing as addiction. Physical dependence means that, over time, the patient develops a tolerance to the drug and thus requires more of it and more often to achieve the same (pain relieving) effect. Sudden cessation of opiates for which a physical dependence exists brings about withdrawal symptoms.

Withdrawal from opiates, whether the patient is physically dependent on the drugs or has developed an addiction to them, should never be undertaken without careful medical supervision. Such medical monitoring helps to reduce or eliminate severe withdrawal symptoms such as restlessness, bone and muscle pain, cold flashes (“goose bumps”), vomiting, diarrhea, insomnia, and involuntary leg movements.

Prerequisite for Treatment for Opiate Addiction

Before treatment for opiate addiction can begin, the patient must be detoxified of all the drugs in their system. This detoxification also must be medically supervised in order to help ensure minimal withdrawal symptoms. So, the first step in treating opiate addiction is detoxification.

Types of Replacement Therapy for Opiate Addiction

There are four types of medications used in replacement therapy for opiate addiction.

Methadone

Methadone, which is a Schedule II synthetic opioid, is the first and oldest treatment used for opiate addiction. It has been successfully used to treat opiate addicts for more than 30 years. It has also been widely used to treat heroin addicts. The advantages of methadone are that it eliminates withdrawal symptoms and helps reduce craving.

According to a 2002 publication from the Centers for Disease Control and Prevention (CDC), Methadone Maintenance Treatment, methadone a) blocks the sedating and euphoric effects of opiates, b) relieves craving for opiates that is a major factor in relapse, c) relieves symptoms associated with withdrawal from opiates, d) with stable dosing, does not cause euphoria or intoxication itself, thus allowing the individual to work and participate in society normally, and e) is excreted slowly, so it can be taken only once daily.

Methadone replacement therapy for opiate addiction generally takes a minimum of 12 months, according NIDA recommendations, although some individuals benefit from continuing to take methadone maintenance treatment for several years. Methadone is safe when taken for 10 years or longer, according to the NIDA.

Methadone treatment has not escaped criticism and controversy over the years. Some argue that it’s just substituting one addiction for another. Since some patients have diverted their own methadone supplies to augment their income, thus serving as a magnet for crime, methadone treatment in the U.S. is heavily regulated and strictly controlled. Previously, methadone treatment was only available through federally licensed methadone clinics. Following revised guidelines introducing office-based opiate replacement therapy, the Drug Addiction Treatment Act of 2000, methadone maintenance treatment is now available through physicians’ offices, licensed clinics and hospital outpatient and other health care settings. Patients who are taking methadone therapy for opiate addiction must be monitored closely if they are also receiving antiviral therapy for HIV infection, to avoid potential medical interactions.

Buprenorphine

Buprenorphine, another synthetic opioid that is classified as Schedule III, is a more recently-approved treatment for opiate addiction as well as addiction to heroin. Buprenorphine is a derivative of thebaine, an opium extract. According to the NIDA, buprenorphine is the first medication developed to treat opiate addiction in the privacy of a physician’s office. This medication has less risk of addiction than methadone. Buprenorphine binds to the same receptors as morphine, but does not produce the same effects. Buprenorphine’s weaker opiate effects are less likely to cause overdose problems and produce a lower level of physical dependence. This means that patients who discontinue taking buprenorphine have fewer withdrawal symptoms than those who stop taking methadone for opiate addiction.

Like methadone, buprenorphine reduces cravings for heroin and other opiates and also reduces withdrawal symptoms. Buprenorphine also has a ceiling effect in that increased doses of the drug do not produce increased effects beyond a certain point. In some individuals taking buprenorphine, higher doses can actually precipitate withdrawal symptoms. It is, therefore, not as effective as methadone in treating severely opiate-addicted individuals who require high doses of methadone daily. According to the Substance Abuse and Mental Health Administration (SAMHSA), the best candidates for buprenorphine therapy are those who receive 30 milligrams or less of methadone. It is estimated that buprenorphine is effective for about one-half to two-thirds of the population of opiate abusers.

The Food and Drug Administration (FDA) approved buprenorphine tablets in 2002. Two formulations of FDA-approved buprenorphine are available. Subutex (buprenorphine hydrochloride) is used in the initial stages of opiate replacement therapy. Suboxone (buprenorphine hydrochloride and naloxone hydrochloride) is used in the maintenance stage.

Naltrexone

Naltrexone is another medication that blocks the effects of morphine, heroin and other opiates. According to a NIDA report, naltrexone, a long-acting opioid receptor blocker, can help prevent relapse. How it works is that the drug blocks the pleasurable effects of heroin and is therefore useful in treating highly motivated individuals. One caution is that it can only be used with someone who has already been detoxified, due to the severe withdrawal effects it can produce in someone who continues to abuse opioids.

Depending on the dose, naltrexone lasts from 1 to 3 days. Naltrexone has proven effective in preventing relapse in former opiate-addicted prisoners released on probation.

Naloxone

This is a short-acting opioid receptor blocker. Naloxone counteracts the effects of opioids and can be used in treatment of overdoses.

Buprenorphine/Naloxone

This combination drug of buprenorphine and naloxone is a formulation designed to minimize abuse.

Other Drugs

Two other drugs may be prescribed to help reduce the severity of withdrawal symptoms from opiate addiction.

Clonadine, according to the NIDA report, is of some benefit, but it has nasty side effects of sedation and hypotension.

Lofexidine, launched in 1992, is a “centrally acting alpha-2 andrenergic agonist” specifically for use in treating patients with opiate withdrawal symptoms.

Is Replacement Therapy Right for Opiate Addiction?

Experts in treating addiction to opiates have a wide range of treatment programs at their disposal. Weighing the benefits of one medication versus another to treat opiate addiction is part of the overall treatment program specifically designed and tailored for the individual patient.

Taking buprenorphine, for example, is more long-lasting than methadone, and can be taken more conveniently – in take-home prescriptions, for example – than going to a clinic each day.

But just taking replacement therapy for opiate addiction will not get at the root causes of the addiction. That’s why a multi-disciplinary approach to treatment works best, using behavioral therapies in conjunction with pharmacologic treatments. This may involve contingency management therapy, cognitive behavioral therapy (CBT), hypnotherapy, and others. Contingency management therapy uses a voucher-based system of points, based on negative drug tests, which the patient can use to exchange for items designed to encourage healthy living. CBT is intended to help modify the patient’s behaviors and expectations related to drug use, as well as to provide them with effective coping mechanisms to deal with life’s daily stressors.

It is important to note that replacement therapy for opiate addiction is not a “magic bullet” that will instantly take away all cravings and prevent relapse. This type of therapy isn’t something that the patient can take now and forget about. It also takes time. To be effective, the patient needs to commit to staying on the medication for however long it takes – usually a period of years. Also of importance is the fact that co-occurring disorders, multiple addictions, and/or a mental disorder, can complicate the treatment program for opiate addiction. According to clinical reports, buprenorphine may make some psychiatric symptoms worse. In that case, addiction treatment professionals may recommend an effective addiction treatment program that includes methadone instead of buprenorphine.

For the best results, patients need to be fully committed to overcoming their addiction to opiates (and any other co-occurring disorders, multiple addictions and/or mental disorders). In many cases, the best results may be obtained through a residential treatment program at a facility that specializes in the treatment of the particular addiction or addiction the patient has.

Bottom line: if you or someone you know is addicted to opiates and is sincere about overcoming addiction, seek professional help as soon as possible. With detoxification, treatment and counseling, opiate addiction can be overcome. As with all addictions, it will never be cured, but the patient can return to a normal, productive and satisfying life.

For More Information

To find a treatment facility specializing in opiate addiction, use the SAMHSA Substance Abuse Treatment Facility Locator or call them at their toll-free number of 1-800-662-HELP. There’s also the Spanish-language helpline at 1-800-662-9832 and TDD at 1-800-228-0427.

SAMHSA also operates the Buprenorphine Physician and Treatment Program Locator. Note that the number of patients that physicians can treat with buprenorphine is limited by law. Therefore, some of the physicians listed in the locator may not be accepting new patients. Since the site is updated weekly, SAMHSA recommends checking back regularly.

Another SAMHSA site for methadone treatment centers is located at the following website: http://dpt2.samhsa.gov/treatment/directory.aspx

More information on treatment is available at the Center for Substance Abuse Treatment (CSAT).