According to the National Institute on Drug Abuse between 1999 and 2010 prescription painkiller sales quadrupled. They also estimate that 80% of prescription painkillers are prescribed by 20% of the providers. Since 1999, overdose deaths from painkillers and heroin have increased by 300%, a staggering number that reflects the current nationwide opiate epidemic. According to the National Survey on Drug Use and Health, heroin dependence doubled from 214,000 in 2002 to 467, 000 in 2012. Opiate addiction (both heroin and prescription pills) have the highest relapse rates than any other addiction. Methamphetamines and Alcohol relapse rates come close but opiate addiction has a staggering 90% relapse rate in the first year; clearly something is not working. In my experience opiate addiction has some unique challenges that other addictions don’t come with. I often say treating addiction is a specialty and treating opiate addiction is a specialty within that. Fortunately, one thing the current epidemic has done is forced treatment providers to rethink how they treat opiate addiction and offer better treatment. A 90% relapse rate is unacceptable, and as a provider I have a part in that. While that statistic probably reflects some people who are not ready to get or stay sober, it also includes people who do want to get sober but have not been provided adequate treatment. Each individual is unique and treatment should be individualized to fit the person, not the other way around.
Treating addiction, especially addiction and mental health issues (dual diagnosis), is complicated and it would be impossible for me to explain how to treat everyone in a short article. My hope is that I can clarify an understanding of why it’s unique and how to use that understanding to help people get better. My goal is to eventually work myself out of a job. One reason opiate addiction has such a high relapse rate has to do with the part of the brain opiates activate, the Opiate Endorphin System. The Opiate Endorphin system releases our body’s natural morphine and is primarily activated in times of pain, pleasure, and bonding. It is highly pleasurable. When opiates are taken, they open the flood gates of this natural morphine and produce a very euphoric feeling. If a person starts taking them regularly or taking more than prescribed two main reactions occur. First, when they regularly open these flood gates they are depleting their natural reserves. Normally, if we get injured and need these endorphins, the brain would replenish that supply through food, sleep, and exercise. However, if they use regularly the brain won’t replenish that reserve. It comes to depend on the opiates the person is providing it to “replenish” it, which leads to more depletion. The other reaction has to do with the opiate “receptors” (these are the key holes that various chemicals bind to unlock the chemical release). Each receptor is meant to accept a specific key, or chemical, like any other lock and key. Since the reward of opiates is so great the brain begins to morph other receptors to accept these opiates; essentially “growing” extra opiate receptors. It’s not actually growing receptors but it stealing receptors meant for other keys to accept opiates. This creates an Opiate Endorphin system with extra receptors that are hungry for opiates (cravings) and a depleted Opiate System, which creates an overall emotional imbalance; and when we are imbalanced we seek to find balance. We still don’t fully understand the brain and how all these systems work but we are learning more each day. Another variable in the high relapse rates has to do with the amount of time it takes for the brain to repair. Tolerance builds so rapidly with opiates it’s as if the brain morphs these receptors virtually overnight; yet it can take months for extinction. We can successfully detox people from the physical withdrawals very quickly, but many opiate addicts express daily cravings even after months sober. I had a client who was clean off opiates for over two months and still had daily cravings. He was on the verge of relapse, as well as riddled with anxiety. After a small dose of Suboxone his cravings went away, his anxiety drastically diminished, and as of the date of this article he has 3 years sober.
As I explained, in addition to these excess receptors that create powerful unconscious cravings, opiate users have also depleted their Endorphin System. They literally have drained it. This system is a neuromodulator, like a hub for other important brain chemicals. It helps regulate the other systems beneath it. I compare this hub to the Sierra Nevada snow pack. If it is depleted, then the surrounding lakes and rivers are low; which impacts the fish, wildlife, agriculture, and our own water supply. This is one reason individuals with depleted opiate systems have tried many anti-depressants with no relief. It’s like trying to fill the oil in a car through the windshield wiper reservoir. Not only can this system be depleted from drug use but there are some genetic factors as well. It is believed much like some individuals can be low in Serotonin (creating depression) or low in GABA (creating anxiety) some individuals can already be low in Opiate Endorphins. This is widely accepted as “self-medication” in the addiction community. It is easy for most people to understand someone who is addicted to alcohol might be medicating a GABA imbalance and that in recovery they may need a medication to balance them. But what medication do the opiate addicts get if they have a natural opiate deficiency? May of my clients that describe the first time getting high on opiates say they wish they had felt that way their whole life, beyond euphoric, they felt “normal.” One can hypothesize this may be an indication of an inherently deficient Opiate System. Some people take opiates and feel nauseous and get sick right away; this could be an indication of a healthy Opiate system that was just overloaded. Some people take opiates and feel calm confident, more affectionate, and more social. This is an indication of a deficient opiate system. This makes treating these opiate addicts even more difficult because just getting them off the drugs still leaves their Opiate Endorphin system deficient.
Since this system is a neuromodulator, an Opiate deficiency can create all types of mental health issues such as depression, anxiety, fatigue, and emptiness. However, psychiatric medications used to treat such conditions do not target the Opiate System so those medications bring little if any relief. I can’t tell you how many clients I have worked with who have been over medicated, misdiagnosed, and treated as if their opiate addiction was no different than an alcoholic. Sure they both are addicted to intoxication, and sure they are both using intoxication to cope, but the treatment of the two has its differences. The good news is there is better help today than there ever has been. An opiate addiction in the 90’s had a very poor prognosis.
For years the only medication used for opiate addiction was Methadone. The benefit of Methadone is it’s affordable and allows users to stay off opiates and function by taking away withdrawal symptoms and cravings. However, Methadone has its down sides. It is a full opiate agonist, meaning it opens the gates fully so there is the potential to get high off Methadone and abuse it. In fact Methadone is commonly abused on the streets. It is also possible to develop a tolerance to it over time, making it difficult to get off of, or even overdose on it. When Methadone is used for detox only there is about a 5-10% success rate. Those that use Methadone long term have better success rates but also struggle with a stigma in the recovery community that they are taking Methadone and thus not “clean and sober.” Also the longer one is on Methadone the more of a tolerance they build.
Luckily in 2002 Suboxone came out. Suboxone has two main chemicals in it, Buprenorphine and Naloxone (not to be mistaken with Naltrexone). Buprenorphine is the primary chemical that helps opiate addicts. Naloxone prevents the user from being able to inject Suboxone. Buprenorphine has outstanding results when used correctly and unfortunately there was a learning curve to understand the best administration of the medicine. There are a growing number of research studies now that are showing positive results when used correctly. Buprenorphine is a partial opiate agonist so, unlike methadone, it only opens the door partially, like a door with a chain lock on it. This allows the medication to take away cravings and withdrawals but for those with an opiate tolerance they do not get high off it. Buprenorphine is also an opiate blocker. This means if the user tries to get high on opiates the opiates skip right off the receptor and they don’t get high. This is a great safety net for those moments of weakness or unexpected triggers. Another benefit we are learning is Buprenorphine appears to have a “healing” effect and can aid in repairing the damaged opiate system in two ways. First, by decreasing the extra receptors that have morphed over time and by increasing the amount of natural Opiate Endorphins, resulting in amazing mood stabilizing benefits (remember that the Opiate system is a major hub for other mood stabilizing chemicals). As of this moment there are trials being conducted that are also starting to research Buprenorphine as a medication for treatment resistant depression and anti-suicidal effects; even in those with no history of opiate addiction. Jaak Panskepp is helping lead this research, a well renowned neuroscientist who did a Ted Talk where he spoke to the potential of Buprenorphine in the treatment of mental health conditions. We really are embarking on an exciting time in the field of mental health and addiction. As if that’s not enough, what impresses me most about this medication is not that it takes away cravings and withdrawals, blocks opiates, and repairs the opiate system; it is the fact that it has a natural reverse tolerance. Over time as the excess receptors heal the individual naturally needs less Suboxone, without being forced. I don’t know any other medication that if taken daily has a reverse tolerance. This is huge considering a major issue for addicts who truly want to get sober is getting addicted to another substance or replacing one for another.
Taking Suboxone is not getting high, being addicted, abusing drugs, or replacing one for another. There are downsides with this medication as well though. The first being it can be used to aid an addict who is not ready to get clean. They will use it to avoid withdrawal until they can get high and then come off it and get high, repeating that process. Another downside is it can lessen their motivation to work at recovery. It can be so effective individuals feel like they don’t need anything but Suboxone to get clean. I compare it to protein powder: If we want to gain muscle we need to take protein but more importantly we have to work out. Just taking protein will not build muscle. Suboxone is effective but it needs to be done in conjunction with therapy and support groups. The other downside is researchers and doctors are finding it is most effective when treatment is long term. The specific time frame is unique to the individual but the success rates sky rocket when it used for a year or more. Success also depends on how developed their opiate system was to begin with. For those with a pre-addiction deficient opiate system, a low dose of Suboxone is more effective than an anti-anxiety medication and anti-depressant. Another issue needing to be addressed besides taking medication is the underpinnings to the addiction. Opiate addiction has strong ties to a history of trauma.
As I mentioned previously the Opiate Endorphin system is activated and “blooms” in moments of bonding. Since trauma is the absence of or the opposite of bonding it directly affects the opiate system. Opiate addiction and trauma often go hand in hand. In my other article I discuss the difference between Relational Trauma and Shock Trauma since many people only think of major abuse when I say the word trauma. A sense of danger or any life threat also sets our nervous system in gear and releases adrenaline to help get us ready to fight or flee. For people who couldn’t shake the trauma off their brain is releasing more adrenaline than it should and if adrenaline can’t be used for anything then it stays in us as anxiety. Opiates actually stop the flow of adrenaline at the source, bringing instant relief. When there is early childhood abuse the response to fight or flee was often not available so people most often dissociate. When we dissociate our body also releases a flood of endorphins to numb us physically and emotionally. So if we just look at what’s going on in the brain and body we can see that some opiate addicts are reaching for the very chemical that eases the system where they have pain, it’s just the wrong medication. A key to successful recovery is not only achieving sobriety but helping the mind and body shake off the trauma through deeper trauma work like EMDR, CRM, Brainspotting, and Somatic Experiencing.
For those that have battled with opiate addiction, and possibly trauma as well, Suboxone is being turned to more and more as the primary medication in their treatment. Unfortunately there is still a huge lack of education around this medication so very few inpatient rehabs, outpatient substance abuse programs, and other treatment providers incorporate Suboxone; and if they do it is usually short term where the research shows poor success rates. Here in Sacramento and surrounding areas we have a flood of opiate addicts yet very few, and I mean a few, sober living homes allow anyone to be on Suboxone. They view it as another drug creating huge problems for people who are stable, motivated, and wanting to work at their recovery and mental health but can’t find safe affordable housing because they are taking Suboxone. To me this is part of the problem and not being part of the solution. When I went to rehab in 1996 I was immediately taken off my anti-depressant because the mentality was to be sober you must be off everything. This type of treatment resulted in many individuals becoming more unstable off drugs than they were on drugs and created high relapse rates.
Since then the thinking around psychiatric medication has greatly improved in the addiction community yet overall the community is behind on the times when it comes to Suboxone. Internet forums are riddled with personal opinions and misinformation by addicts that think they understand the science but really do not. With a 90% relapse rate something needs to change. Recently a research trial found that the short term low dose Buprenorphine treatment plan retains fewer people than methadone treatment. All too often people and treatment centers are trying to quickly taper off Suboxone as quickly as possible. This often leads to relapse, not long term sobriety.
Medication alone is not the answer but we cannot ignore what the research is telling us. Just as addicts need to be open minded, willing to take suggestions, stay flexible, and not live in a black and white world the treatment community needs to lead by example. A shift in thinking is necessary; I have personally witnessed many individuals get well that have struggled for years. They have been to several treatment centers, lost friends and family, and were told they were mentally weak or spiritually limited. With an integrated approach of biological, social, psychological, and spiritual interventions they become healthy, stable, productive members of society and begin to thrive rather than just survive.
Thank you,
Curtis Buzanski, LMFT, LAADC
