I was very uneducated about medications that are effective for substance use disorder (SUD), especially opioid use disorder when my son, Aaron, was still alive. Although he was familiar with Suboxone and methadone, now I believe both of us could have been better informed about how to use methadone along with other support tools that were needed in order to make the treatment the more effective.
Prince’s death has brought the use of Suboxone, a medication that is used to treat opioid use disorder, and the idea of medication-assisted treatment (MAT) for substance use disorders to the forefront of the opioid overdose epidemic. The latest statistic from the National Institute on Drug Abuse (NIDA) is that 129 people are dying every day in the United States from drug overdose; 80 of those deaths involve the use of an opioid.
I believe the stigma and discrimination that accompany substance use disorders, also accompanies the medications that can be used to quell withdrawals symptoms and lesson cravings for those with substance use disorders as they seek recovery.
MAT can greatly reduce the possibility of relapse which often lead to drug overdose that can result in death.
Suboxone
Suboxone, the MAT treatment that didn’t get in Prince’s body soon enough, is one of the medications that is often used to quell withdrawal and cravings for opioids. What exactly is Suboxone? It’s referred to as a partial agonist because it doesn’t bind to the opioid sites as does a full agonist so it produces much fewer endorphins. Because of its “partial” nature, it is much easier to withdraw from than a full agonist like methadone. Suboxone is the commercial name for buprenorphine (partial agonist) combined with naloxone, an opioid antagonist which is very effective at blocking euphoria when combined with the buprenorphine. Used alone, naloxone (Narcan®) is used to reverse opioid overdose if administered in a timely manner. Suboxone is also available as a film which is dissolved under the tongue thereby lessening the potential for abuse even more. In May of 2016 the FDA approved a buprenorphine body implant that will dispense medication for up to 6 months but has not stated when in will be available for use.
Methadone
Other readily used medications are methadone (mentioned above) and naltrexone. Methadone is a long-acting opioid agonist medication that is very effective in treating heroin and prescription pain medication addiction. It can only be distributed at specifically licensed clinics. Initially it needs to be dispensed every day requiring the user to make daily trips to the clinic. When the specific dose is determined that stabilizes the patient, then patients can begin to lessen their visits by receiving seven days of doses divided between two or three days a week and eventually, only coming in once a week to receive all seven days for the next week. This daily commitment combined with the difficulty many have in tapering off the medication (and its potential abuse as a full agonist that can be sedating) often outweighs, for some, the positives of its effectiveness in quelling withdrawal and cravings. Methadone is also much less costly than Suboxone if the user needs to pay out of pocket.
Naltrexone
Naltrexone is another MAT drug, but is an antagonist. This means it blocks any opioids from connecting to the receptor sites and can only be used after a patient has completed detoxification from all opioids and all opioid medications like Suboxone or methadone. If a patient uses it while any opioids are in the body, they will go in the immediate withdrawal. Naltrexone is not addictive or sedating and does not result in physical dependence as does Suboxone or methadone. However, poor patient compliance with the daily tablets has limited its effectiveness. A long-acting form of naltrexone called Vivitrol® is now available in a once per month injection eliminating the need for daily use which improves patient compliance. Unlike methadone or Suboxone, anyone licensed to dispense medications can prescribe naltrexone, but the cost may be prohibitive for many.
1990’s Perceptions & Protocols
My history with MAT goes back to the 1990’s when most people considered substance use disorders a character flaw, and/or lack of will power and motivation. Although the American Medical Association (AMA) recognized alcoholism as disease in 1956 which allowed it to be viewed as a diagnosable condition for which insurance reimbursement was possible, most treatment focused on it being a psychological/behavior disorder. This was the treatment protocol I learned in graduate school in the early 90’s.
Addiction Recognized as a Progressive Brain Disease
Aaron died in 2007. It wasn’t until 2011 that The American Society of Addiction Medicine (ASAM) first stated that addiction is a progressive brain disease that is fatal without intervention.
This meant both of us went through our 20-year struggle with his SUD without knowledge of addiction being a brain disease – as I suspect many have. It was a wake-up call for me to learn that this illness is “about underlying neurology, not outward actions.”
The NIDA soon after stated that addiction is “a chronic relapsing …brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” It was so hard for me to grasp that my son’s was ill not only with a physical dependence – but also a psychological compulsion that would create drug seeking behavior no matter what the consequences. Abraham Maslow’s Hierarchy of Needs is a theory of psychological health predicated on fulfilling innate human needs in a specific priority. Physiological needs such breathing, food and water are at the bottom the hierarchy. In other words – a human’s first priority is sustaining life. The hierarchy culminates in self-actualization at the top. The compulsion that is characteristic of SUD precludes those basic physiological needs.
This why many need MAT to get their cravings quelled. If the cravings aren’t under control, they can’t even think about meeting those basic needs of life – so they can go on to recovering their life.
Tapering off or Long-term Maintenance?
In 2007, most people on MAT methadone programs were encouraged to start tapering off of the methadone once they had been stabilized for weeks or a few months. The yo-yo effect of trying to taper and failing to find the correct dosage created constant turmoil for Aaron as well as frequent relapses. At that time, both of us attended recovery support groups which promoted that if you were on medication-assisted treatment, you weren’t really in recovery because you were still using an opioid medication. And this continues to happen today.
Very few supportive services were offered along with Aaron’s MAT program – which I now know is very important to MAT recovery. You can’t just take a pill or get an injection and recover from this illness. Although behavior and psychological issues may not be a CAUSE of this illness, they do result as we try to SURVIVE the illness. That’s why MAT needs to be offered along with individual or group therapy, peer recovery support groups, classes on exercise, nutrition – basic life skills – keeping a budget and learning how to seek employment. Minnesota Recovery Connection, like many other recovery community organizations (RCOs) in other states – offer many of these resources on their website and support all pathways to recovery.
Suboxone Then and Now
The availability and use of Suboxone is very different now than when Aaron’s final attempt at recovery took place. Then, health insurance paid for Suboxone only when it was administered through an in-patient treatment facility. It was used mainly as a detox tool, not a recovery treatment tool as it is now. Many addiction specialists now recommend that patients with an opioid addiction may be best served with indefinite MAT therapy. There were not many treatment centers licensed to dispense Suboxone and very few doctors licensed to prescribe it. This continues to be a challenge in the treatment world. Many physicians still choose not to seek licensure to dispense Suboxone because they don’t want to deal with the population of people ill with a substance use disorder. Another way the stigma and discrimination still play into the availability of MAT.
What is True Recovery?
I used to think complete abstinence from methadone, buprenorphine (Suboxone), or naltrexone used in MAT, was the only marker for true recovery.
Everything I have learned about SUD and recovery since Aaron’s death tells me that I had a very narrow and uneducated view of what may be necessary to keep the person with an opioid use disorder alive so recovery can happen.
The more options available for MAT to those with SUDs who seek recovery, the better are their chances of remission and the more lives we save. Since Aaron’s death, I have seen and heard many testaments to the effectiveness of all three of these medications when they are used as recovery tools. But the availability, cost and insurance coverage needs to align in support of these life-saving medications that can prevent overdose deaths.
Evidence-Based Treatment
It’s imperative to remember that MAT programs are evidence-based treatment (EBT) protocols. This means there’s scientific research to back up the practice of medication-assisted treatment as a viable treatment option. In general, the research proves that people on MAT have fewer relapses, live longer and stay in recovery longer than those who do not use it. This is especially true for those with opioid use disorder.
Education is the Key
I believe lack of education about addiction being a brain illness and the public not being properly informed about the life saving properties of MAT is what killed Prince along with the additional 128 people who died of a drug overdose on April 21, 2016. Chronic pain might have brought him to where he was with his illness, but in my opinion, ignorance and stigma kept Prince and those close to him from asking for the right kind of the help, at the right time.
Saving the lives of those who are ill from this disease will only happen when the general public becomes educated and demands that the people who suffer from these disorders, deserve the same medical treatment and compassion as does anyone suffering from a chronic illness.