Our last opiate addiction treatment article from Whole Health in West Palm Beach, FL., explained the definition and use of MAT or Medication Assisted Treatment, in addressing patients struggling with particular substance use disorders.
The first article examined the use of opiate agonist MAT therapy (i.e. buprenorphine products/”Suboxone” and methadone),) while this installment will examine the utility of opiate antagonist MAT therapy. The principle disorder to be focused upon, primarily because of its ubiquitous nature and the fact that we are predicted to experience greater than 50000 fatalities this year (MORE THAN AUTO ACCIDENT DEATHS,) is opiate use disorder.
Understanding Medication Assisted Treatment (MAT)
First, a very brief and simplistic review of neurobiology as it pertains to addiction. Opiate addiction is all about the reinforcing experience the patient’s behavior has upon the brain’s dopamine levels (the “feel good” neurotransmitter.)
All addictions, whether they be substance-based, or behaviorally oriented (such as gambling and sex addiction) are rooted in the basic fact that these activities cause a surge of dopamine in a specific part of the brain known as the nucleus accumbens. This dopamine surge is perceived as the “high.” This feeling is obviously pleasurable, and the patient wants to repeat and repeat the addictive activity, as the dopamine release becomes a positively reinforcing result of the behavior.
Opioids and Medication Assisted Treatment (MAT)
In the case of opioids, when these drugs attach to the brain’s “mu” receptors, the result is a huge surge of dopamine, which floods the nucleus accumbens, resulting in an intense and euphoric “high.” The patient uses again and again to keep experiencing that dopamine high, and if they stop using they get extremely ill with withdrawal symptoms.
Therefore, the actual use of the drug is reinforcing, while cessation of use causes them to feel horrible (i.e. Not using is NEGATIVELY reinforcing.) This “double whammy” almost guarantees that an opioid addict will continue to use and/or chronically relapse (if you recall from the first article, the “success rate” of stand-alone abstinence-based treatment such as various psychotherapy, 12 steps, etc. is only around 10% at best.)
MU Receptors Oral Naltrexone, Vivitrol and Naltrexone Implants
It is at the brain’s mu receptor sites where antagonist MAT therapies exert their effect. Antagonist MAT therapies include oral naltrexone, intramuscular Vivitrol, and the off-label use of naltrexone implants that typically provide up to three months of medication with each implant. All of these formulations function in the same fashion- they bind to the brain’s mu receptors very strongly (much stronger than opioids,) preventing any opioids from reaching the patient’s brain and causing that euphoric dopamine surge.
In other words, with antagonists at work the patient will not derive any high from opioids should he or she decide to use them. Therefore, this breaks the cycle of positive reinforcement and helps patients with opioid cravings because they know if they use they will simply not derive the expected and desired feeling. The various formulations primarily differ amongst one another in how compliant the patient is likely to be on the given therapy.
Generally, the injection, or implant are much more efficacious than the daily oral naltrexone, because the patient can forget or “forget” to take the daily naltrexone, but the injection or implant is in their body for one or three months, respectively. Incidentally, MAT antagonist therapy (MAT Part 2) helps immensely with alcohol cravings, and there is emerging evidence that they may be useful for other addictions as well, but that is another topic entirely. However, to stay focused on opioids, I think you can see how incredibly useful antagonist MAT can be in extinguishing the Pavlovian behavior of opiate addicts, and really assist them in putting together solid, long-lasting sober time, and often permanent sobriety!
Abstinence for up to Two Weeks (Understanding the Use of Suboxone)
What is the catch? The primary and most frequent and frustrating problem in initiating antagonist therapy is that, depending on what type of opioid the patient was using, we need anywhere between one and two weeks of total avoidance of ALL opioid and opioid-related products. This includes buprenorphine products (i.e. Suboxone) and methadone. Therefore, for instance, we can’t take a heroin addict, stabilize him or her on Suboxone, and then transfer immediately to naltrexone/Vivitrol/naltrexone implant.
Similarly, we can’t take a patient right out of detox (opioids are actually used to detox opioid addicts) and transfer them to antagonist therapy. The reason is that, as stated, the antagonist has a much stronger affinity for the brains mu receptors. If there are any opioids occupying those receptors at the time that antagonists are introduced, they will “kick off” the opioids and result in severe withdrawal for the patient.
Reasons Why Many Do Not Get Antagonist Therapy (Naltrexone and Vivitrol)
So, the primary issue becomes how do we get the patient to be abstinent for the requisite one to two weeks so that we can utilize this effective antagonist therapy? Unfortunately, many addicts are unwilling or unable to be totally devoid of any and all opioids (including Suboxone or methadone) for more than a couple of days before feeling so horrible that they go right back to using. This is, indeed, the eternal challenge of initiating antagonist MAT therapy, and probably the most frequent reason why it is not implemented in more recovering addicts.
There are other reasons as well- not the least of which is a patient who refuses antagonist therapy because they are scared they won’t be able to get high (they are not “ready” to live a sober life.) Other potential downsides to antagonist MAT is that they can cause nausea, occasionally worsen, or cause depression, and can cause liver inflammation (many of our patients have alcoholic, or viral hepatitis, so this is a particularly relevant concern.) Of course all of these potential side-effects are closely monitored and actually different forms of antagonist therapy tend to have more or less of these side-effects, but they are concerns nonetheless.
Antagonist Therapy is Not Habit Forming (Naltrexone and Vivitrol)
In summary of our MAT Part 2 education, antagonist MAT can be incredibly helpful in the treatment of opioid use disorder (and other addictions,) assuming the proper timing of treatment initiation, and appropriate patient selection. Antagonists are not narcotics, are not habit-forming, and have no discontinuation syndromes.
I typically shoot for a twelve month period of closely monitored treatment in my opioid addiction treatment protocol at Whole Health in West Palm Beach FL. With the continuation of cognitive based therapies such as structured PHP/IOP/OP programs, NA/AA, 12 step work, spiritually based programs, or whatever positive and helpful course of psychotherapy my patient gravitates towards. Success rates (which I define as prolonged abstinence- greater than one year) utilizing this methodology in my practice have been impressive and encouraging.
The real question is how to effectively bridge the gap between opioid use and antagonist MAT so that we don’t lose patients to recidivism secondary to severe discomfort.
Comfort Meds and FDA Unapproved Meds
There are some “comfort meds” we use with variable efficacy, such as clonidine, vistaril, baclofen, trazodone, etc., but these are rarely able to accomplish bridging of that gap. There are other methods of bridging this gap, including plant-based detox regimens (i.e. Ibogaine) that detox the patient without the use of opiates, which are extraordinarily interesting and deserving of further research, but they are currently not legal for use in the US. There is also a exciting new non-pharmacologic, “non-substance” device called the Bridge device, which when installed on the patient’s ear, can significantly or totally ameliorate withdrawal symptoms, also without the use of opiates.
As usual, insurers presently consider this modality experimental and will not reimburse for its use (though I am optimistic that this will and should change.) If we could just bridge that gap we could really get a lot more patients on effective antagonist therapy, and this is where I truly believe that what the recovery community at large deems “true sobriety” can be much more frequently attained. Until then, I will continue to pray for progress and utilize the appropriate available medications to assist my patients in the avoidance of death, and the realization of the most rewarding and fulfilling lives they can possibly experience.
“We,” collectively in the recovery treatment community, owe it to our patients to place whatever personal biases we may possess aside, and make this our unified and uncompromising goal at all times!
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You may also be interested in some of our other articles on addiction treatment; “Unchecked Addiction Treatment Diseases“, “What Does (MAT) Medication Assisted Therapy Mean for Generation Z?“, and “Narcan Education by Opiate Detox West Palm Doctor“.