EXCHANGE: Medication aids helps to ease opioid dependency
PEORIA, Ill. (AP) – Cecily Melton, 30, shook her head quickly when asked if she could have tackled her opioid habit without help from a medication called Suboxone.
“No way,” said the mother of five, more than three years after she weaned herself off opioids and restarted her life.
“I think I could have managed to get off it, but is recovery just getting off pills or is it in the mental health you get while you get clean? I don’t think that I would have managed as well as I have done now without the people who have helped me along the way.”
A former Army wife, the Bartonville native became addicted to opioids several years ago after a military base physician prescribed her a dose of painkillers for her baker’s cysts, a buildup of fluid behind the knee. She took the drugs faithfully and didn’t realize something was wrong until her prescription ran out.
“A military doctor prescribed me Percocet. Anytime I’d have a cyst, anytime I’d go back in, they would prescribe me another script. It was continuous.”
“I didn’t feel like myself. I didn’t want to get up and take care of what I needed to do for the day. I wouldn’t function. I started to buy them off the street. But it doesn’t stop you. It doesn’t stop you from feeling right.”
She’s one of the lucky ones. She came back to the Peoria area, realized she needed help and found that help with the Human Service Center’s outpatient, medication-assisted treatment program.
Suboxone, a brand name for buprenorphine, is one of three drugs approved by the Food and Drug Administration for opioid treatment. The other two drugs are methadone and naltrexone.
One recovery specialist estimates about 1,500 Peoria-area people are involved with local clinics for Suboxone and methadone alone. And there’s a waiting list.
“It’s just like any medication, and I know it’s controversial, but would a very depressed person be able to stand up and go along with their day without their depression medication? Yeah, probably, maybe. But because they have that mental stability and help, they will probably do a lot better,” Melton said.
Experts say the medications work differently and, depending upon one’s addiction and situation in life, one medication might be an option whereas the others might not. Regardless, addiction medicine doctors say treatment with medications is proven to work better than going cold turkey.
“The evidence is clear that these medications can help stop the disease, cause remission and save lives,” said Yngvild K. Olsen, medical director for the Institutes for Behavior Resources Inc. in Baltimore.
Dr. Marc Fishman, a researcher at Johns Hopkins University, also in Baltimore, spoke at the American Society of Addiction Medicine conference this past spring in San Diego. He does clinical work with adolescents who suffer from opioid use disorder.
He says medications aren’t the only way to treat opioid use disorder, but “60 plus years of data have shown that they are our best tool but not our only tool” for what he called, “medication-assisted recovery.”
Chrissy Smith, program manager at the Human Service Center, oversees the HSC’s outpatient medication-assisted treatment programs. She said medication is part of an overall recovery plan that includes counseling and life skills training.
“The majority of opioid users would not stop using opioids without medication-assisted treatment. Could people go cold turkey and stop? Maybe, but their long-term success is better with the medications. Medication-assisted treatment (MAT) helps people get through the cravings and withdrawal so they can manage some of the other things that are essential to recovery,” she said.
People like to see these drugs as a cure, when, in fact, there is no cure. And using methadone and Suboxone and other medications requires a commitment from someone who is willing to either show up to a clinic or to follow through with a prescription.
“It’s a chronic brain disease, so there are some people who will need these drugs for the long term. Some might need them for the rest of their lives. However, just like hypertension and diabetes, medications by themselves often are not what is going to help the person manage their disease,” Olsen said.
Where exercise helps with diabetes and can allow a person to come off insulin and manage their blood sugars, people who are on methadone or buprenorphine can possibly taper off those drugs. Others might not, she said, but the stigma of addiction and of using drugs can often cause people to not even try.
Medication-assisted treatment for opioid addiction has been around for decades. For years, methadone clinics dotted urban centers as a way to combat heroin abuse. Buprenorphine came on the scene about 25 years ago, and, in 2010, the FDA approved an extended release version of naltrexone, a drug used for years to treat alcoholism, as a third alternative.
All the drugs interact with the receptors that are activated in the brain by opioids. But how they do that and what effect they have on the person differs.
Think of a receptor as having a U shape on top of a stem. Buprenorphine and methadone both fit within those receptors. The drugs, whether it’s heroin or methadone, are small little balls that drop snugly within that U-shape, but they work differently. Both methadone and buprenorphine treat the withdrawal and reduce the cravings a person with an opioid addiction experiences with drugs such as heroin, fentanyl, Oxycontin or Vicodin.
Methadone is a full agonist, which means one ball for one receptor. Buprenorphine is a partial agonist, so it takes more than one ball to fill the receptor.
“This is why some folks can find stability with one medication but not the other, and is what makes the medications different,” Smith said.
Using methadone or buprenorphine can out-compete heroin for the receptors. Taken once a day under appropriate medical supervision, a person can stabilize and not go through withdrawal while staying away from overstimulating the receptors that cause that “high” sensation.
The down side? A person needs to take these medications consistently, like they would a blood pressure medication, and they are short acting. Methadone is a daily dose administered at a federally-approved and secure site.
Buprenorphine, more commonly known by its brand name Suboxone, can be obtained through a prescription at a drug store such as CVS or Walgreens. They are generally, like methadone, taken daily, but some people can take it every other day, depending on the dose.
Injectable naltrexone works differently and has been formulated for a monthly dose. It’s possible the drug, which was originally used to treat chronic alcoholism, could be taken daily, but that’s not as common.
It doesn’t stick within the receptor, Olsen said, but sits on top of it. It doesn’t activate that receptor at all, but it does block any other opioid from getting to that receptor. It’s a single injection that can last for up to a month.
The downside: A person needs to be opioid free for at least seven to 10 days. And that’s a significant challenge for people with an opioid addiction, experts say.
“If they are currently under the influence of an opioid, then the shot will put them straight into withdrawal. It’s a blocker. It blocks the receptor that the opioid attaches to,” said Tyrone Wilkins, clinical supervisor with the Gateway Foundation.
Wilkins says the good combination for some is to get on Suboxone to handle the withdrawal and slowly wean off that so they can take an injection of Vivitrol.
There are several providers within the Peoria area that provide these options. Smith said there are three methadone and three Suboxone clinics in the area that treat an estimated 1,500 people and there are still people on a waiting list. Vivitrol injections are administered by the Gateway Foundation, but there’s another place that Sheriff Brian Asbell hopes it’s administered as well – the Peoria County Jail. He’s applied for a grant to cover the cost of creating a program at the jail, where some inmates suffer from opioid addiction.
Ravi Doshi, a case manager for the Gateway Foundation, oversees similar programs at other county jails, including Tazewell County Jail.
Gateway started the program there in June and already has 16 active clients. Doshi said the program has been well received by all parties.
“It’s a no-brainer,” he said simply.
There are two requirements. A person must show they have an alcohol or opioid abuse issue. They must also have a date when they are to be released from custody. The second part has required cooperation from the state’s attorney’s office, public defenders and probation officers as well as judges. So far, things have gone well.
Detainees have been embracing the program, Doshi said.
“They are very receptive. A lot of them have never gotten substance abuse treatment before. And we are able to show the court and the criminal justice system that the reason they did the crime in the first place was to fuel their addiction.”
But as with other programs, it doesn’t stop with a nurse giving a shot. Rather, there are “recovery coaches” to help a person once they are released to deal with the issues that could cause them to relapse.
Issues such as employment, housing and transportation are addressed. The coach is a community member who is there for the former detainee. It gives the client the “best shot” at recovery.
“When people come in here, we have a way to keep them off drugs for seven to 10 days. It’s a good place for us to try it as they can’t use (drugs) while they are in custody,” Doshi said.
His dream is to use the space that once housed inmates on work release as a public detox center. That way, people are in a structured environment while going through withdrawal and can get onto Vivitrol or some other medication.
“The jail is a unique opportunity for detox because people are incarcerated as opposed to trying to do this on the outside,” he said.
One of Asbell’s ideas is to offer the program to people who come in on drug-related crimes. They could opt into the program and perhaps voluntarily stay at the jail for a week or so, so they could get on the Vivitrol treatment plan. That part is key, the sheriff said, as many people who come into the jail are there for less than 48 hours. That’s not long enough to be evaluated and certainly not long enough for someone to get onto Vivitrol.
As part of their pre-trial release, they would have to participate in counseling and other therapy deemed necessary by counselors or case workers. The county’s probation and state’s attorney’s office would also be involved in the program. While he didn’t mention it, the idea is like an extension of the drug court program that occurs after a person is indicted.
This could mean community-wide involvement in the program.
Sophia Dawson, a counselor at the Human Service Center, said these drugs are not the solution for a person’s struggle with opioids or addiction in general. Rather, she said, they can assist a trained specialist to help a person recover.
“We have the option to do Suboxone or methadone. I had a person who was struggling with Suboxone, wasn’t getting what he needed from that because with Suboxone one tends to meet weekly (with a counselor). With methadone, you are meeting with them daily,” Dawson said. “Maybe he wasn’t getting enough one-on-one counseling. There is more to getting clean and living in recovery than just the medication. I think that speaks to clean and sober.
“Just because we may take the drug away doesn’t mean that everything is rainbows and unicorns,” Dawson said.
Still, Melton, the recovering opioid addict, said her life is like “night and day” since she entered into the Suboxone program at HSC.
“I have relationships with my family that I didn’t have for a really long time. I have relationships with my kids that went away for a long time. I have relationships with people from around town who knew me as a drug addict,” she said. “It saved my life. I was on the very verge of heroin before I walked into this clinic.
“I am one of the very lucky few that got out before my foot was in that grave.”