Treating Opiate Abuse:
Buprenorphine (trade names Suboxone and Subutex) & Support
Jon Daily, LCSW, CADC II
Claude Arnett, MD
As mentioned in my previous newsletter, opiate (oxycontin, fentynal, heroin, etc) abuse/dependence is on the rise both locally and nationally.
How do these drugs work?
All drugs of abuse create intoxication. Each drug that is abused targets different neurotransmitters and regions in the brain, but at the peak of the intoxication an opiate / endorphin release occurs in the body.
What is the purpose of the opiate / endorphin system?
The opiate / endorphin system was not meant to be activated with synthetic street drugs. It is meant to help us manage stress, emotional/physical pain, experience pleasure and reinforce behavior. Maybe most significantly, it is a neurological core component of “secure” human attachment to caregivers in our early childhood experiences.
What does this intoxication feel like for the user?
Opiate drugs target that pleasure, bonding and euphoria system most efficiently. The experience for the user is equal to, and in some cases greater than, the feeling a parent and newborn have when mutually gazing into each others eyes. It can also be likened to the first time their child reaches out to hug, kiss or tell their parent they love them. That feeling is very rare, and that experience can never be the same after the first time. This feeling, experience and attachment occurs for the opiate abuser when they are using. Sadly, they become quickly bonded with that experience from the intoxication and because that experience is so powerful they want to do whatever it takes to have that experience again and again. However, it is never the same for them as it was the first time. Yet they long for the warm embrace of this intoxication.
The Hijacked life:
Eventually the opiate / endorphin system becomes broken due to the toxic insult of the drug to the brain and body over time. The user becomes dependent on the drug no longer to get “high”, but just to feel normal. At this point the user is no longer seeking that first intoxication, rather they are just trying to avoid the physical (stomach problems, back pain, joint pains, sickness) and emotional (emptiness, isolation, depression, despair) withdrawal. The user has become completely hijacked by the drug, and caught in the grip of addiction. They are now a slave to the drug. Their mind and life has become preoccupied with how to get and remain high at any cost. Their values have been transformed and reorganized – where they were once a great person, attending school, sports, practicing music, hanging out with friends, going to work, etc, they are now violating themselves and others and neglecting important areas of their life to seek the drugs. They are good people caught in the grip of a bad illness.
Treatment & Methadone:
Because opiate abuse powerfully hijacks a person’s brain, body, mind and ethics, the medical field has worked diligently to discover medications to help opiate abusers manage the already mentioned withdrawal symptoms. The thinking has been that if the withdrawal symptoms can be managed then the user will be less preoccupied with seeking the drug. Therefore, the users will not commit crimes against society in the process of trying to support their habit. In addition, they can use their freed up mental energy to focus on their recovery and other responsibilities.
For many years methadone has been the primary medicine of choice for this population. Methadone helps to manage the withdrawal symptoms which frees up the addict’s body and mind to focus on other things such as recovery, family, vocational training, work, school, building support in their life, etc. The downside to this medication has been that it too can cause intoxication, addiction, and in some cases death from overdose.
New medications: Buprenorphine
On October 8th, 2002 the FDA announced the approval of Buprenorphine (trade names Suboxone and Subutex) forthe treatment of opiate abuse. However, the medicine can only be prescribed by medical doctors who have a special certification in the treatment with this medication. Luckily there are increasingly more doctors in our area becoming certified to prescribe this medicine.
How does it work?
Buprenorphine is a partial agonist of the endorphin receptor, which means it opens the door to the receptor, but with a chain lock, so there is a limited amount of stimulation. Other opiates, like Methadone open the door completely. The more one takes methadone, the more it effects the system. That is why users can overdose on Methadone and cannot overdose on Buprenorphine. Buprenorphine binds more strongly than any other opiate except Fentanyl. Buprenorphine has two effects: analgesic–reduce pain, feel normal, lasts about six hours; Blocking –subtle psychological effect, but blocks other drugs (Oxycontin, Vicadin, etc) from binding to it for 36.5 hours. Most people take Buprenorphine 2-3 times per day to maintain the “feeling ok” state. The interesting thing about Buprenorphine is that it has the subtle effect of partially closing receptors that have been wide open. So if someone is very aggressive and loves to take risks, it will partially close the reward for that so they will not get as much pleasure out of being aggressive and chasing risks. Buprenorphine partially opens receptors that have been closed down. So if the same person does not get much reward from avoiding a disaster, then they will experience being more anxious in the face of high risk behavior and feel more sense of relief about avoiding something likely to be hurtful. This is a great opportunity in therapy because you have the chance to really work with altering someone’s temperament and how it drives them. It is also a risk of Buprenorphine, because people experience themselves as “different” and need help understanding and managing that. The last thing about Buprenorphine is that there is some evidence that prolonged use actually heals the receptor system. Most people use less and less of a dose and maintain the same stability. (partial agonists have this effect–like Abilify, Lithium, Buspar). Finally, Buprenorphine has been shown not to work well for people using over the equivalent of 120mgs of Methadone per day. It seems not to be able to get those users out of withdrawal.
What else is needed in the treatment of opiate dependence?
In my practice, Buprenorphine has been a powerful piece to the puzzle in helping to treat opiate addiction. However, it is not the panacea. Long after the withdrawal symptoms are gone, most clients are still lonely, anxious, and full of shame and guilt about what they have put themselves and the people who care about them the most through. They feel compelled to turn away from people and be “unseen” vs. turning to people to be seen and supported. Of course turning to others and building support in life are much easier said than done, but it must be noted that this process has to occur as a significant part of a person’s recovery in order to eventually discontinue the medication.
The role of support & the repair of the self
The field of interpersonal neurobiology with the work of Dan Siegel, MD and Alan Schore, PhD has taught us that when people have the experience of “feeling felt” by others it not only heals them emotionally & psychologically but neurologically as well. A person “feels felt” when they have the experience that others “get them.” It is the experience that others can attune to the person’s emotional, psychological and physical states.
The importance of attunement coincides with the 12-step community’s cliché “that one addict helping another addict is without parallel.” An addict who has become sober knows exactly what another addict trying to become sober is going through. The experience between them of “feeling felt” is without parallel in terms of how powerfully therapeutic that experience is for them. During attunement they become validated, learn to trust themselves and others. This is the foundation of “being seen” again and taking the big, yet important, risk of turning to others for help. In addition, during attunement the opiate / endorphin system is activated and dopamine is released which helps to repair the brain to work the way it was intended to. When a person has built consistent, warm and nurturing support and they have learned how to ask for and receive help, they are well into their process of emotional, psychological and neurological healing. For many recovering addicts, at this time the medicine has become replaced by secure attachments and social support systems in their lives.
Jon Daily, LCSW, CADC II