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Replacement therapy as addiction treatment – Why it makes sense

December 2nd, 2010

I’m a little sick and tired of hearing discussions that continuously talk about opiate replacement therapy (think methadone, suboxone, subutex) as not being true addiction treatment because those individuals are still using a drug. While some recent advances will hopefully allow more and more people to achieve medication assisted recovery through antagonist therapies (like naltrexone and its once a month wonder Vivitrol), agonist therpy, or replacement therapy, has been working wonders with heroin addicts and other opiate addicts who have tried quitting multiple times and have failed only to succeed wonderfully using these medications.

What replacement therapy as addiction treatment looks like

A recent comment on this blog compared using suboxone to get off heroin to drinking beer while trying to quit liquor. Let’s assume for a second that this is a worthy comparison (although buprenorphine is a partial agonist for opiate receptors and not a full agonist), the one thing it’s missing is context, so let’s give it some: take Paul, a daily drinker who puts down a fifth of Vodka or more on a daily basis. He’s been doing this for years and the physical toll has been immense – His liver is failing along with his health and his pasty white skin looks good with his shuffling and  Wernicke-Korsakoff syndrome due to improper thiamin (vitamin B) intake. He hasn’t been able to hold down a job for years due to the shaking and blacking out not to mention the need to always have alcohol around for when the withdrawal starts. He’s tried to quit drinking several times but the DTs, shakes, and generally horrible feeling almost always makes him go back to drinking soon after and even the few attempts at medically supervised addiction treatment failed when he relapsed within weeks of leaving treatment. One day, someone promises Paul a solution to all his problems and gives him a magical beer that he has to drink in the morning when he wakes up. Not believeing it, but figuring “what the heck,” Paul keeps drinking all that day but then remembers to take that pill early the next morning… He still drinks that first day, though not as much because he doesn’t feel like he needs it, and day by day he begins to consume less liquor and finds himself having that one beer in the morning and sometimes another in the middle of the day. Within a few weeks he’s drinking no more liquor and all he has are those two beers every day. He feels great, has started getting some color back and is looking healthier than ever. He’s even managed to get a little job, though he’s not overcommitting yet not fully believing that this will really last. His memory returns fully and he feels like he did 20 years earlier, hardly believing he’s given so much up for that liquor he doesn’t really want anymore. A year later Pual feels like a new man and never looks back.

Keeping our options – Replacement therapy included

As far as I’m concerned that story, which we hear over and over with buprenorphine-using ex heroin addicts, is not only worth keeping patients medicated forever but makes the notion of not offering replacement therapy when it is appropriate simply crazy. I didn’t even get into the fact that reductions of this kind in heroin use bring about other great health benefits like lower injection rates that bring down HIV/AIDS and hepatitis C infections not to mention all the other complications that injecting is good for.

Like we’ve said many times here on A3, there is no single addiction treatment that will work for everyone but it is absolutely crazy to dismiss therapies that have been repeatedly shown to work (yes, including AA and other 12-step based approaches) and make lives endlessly better. We have a whole box full of addiction treatment tools, let’s not start trying to hammer with a flathead screwdriver please…


Posted in:  Medications, Opinions, Treatment
Tags: , , , , , , , , , , ,
 

7 Responses to “Replacement therapy as addiction treatment – Why it makes sense”

  1. Chuck Tucker says:

    Buprenorphine research conducted by SAMHSA and recent information contained in the periodical Addiction Professional (NAADAC) pretty much comfirms what you’ve written here. However, let’s be clear that addiction patients, at some point, should be tapered off suboxone. It is not, to my knowledge, meant to be a “forever” drug.

  2. JRMDA says:

    I personally know many many people who have used suboxone/subutex (Me included) for 6mos and longer with nothing but the best result possible. The few I know, who have decided to not take it and rely solely on will power, have always relapsed, multiple times. It works! And from what I learned from a neurologist/researcher who’s life work is drug addiction and what it does to our brains, the longer you take it, the better your recovery. It fixes the receptors in the brain. I had to fire my psychiatrist, because he was harassing me about stopping it because he felt I wasn’t fully into recovery if I was still using it! I am a completely different person because of it! I am back to ME! I am a better person, wife, mom, volunteer, etc…
    It’s not just another drug…it’s a wonder treatment and I will use it for as long as necessary!!!

  3. This is 12-step nonsense. There are many AA/NA groups out there, I know I’ve been to them, who chastise people for taking any kind of psychoactive (whatever that means) medication in recovery because then it’s not ‘real’ recovery, it’s cheating. Rubbish.

    Have you ever seen the coffee table at these meetings, and the smoking!!??

    I, personally, think the main aim of treatment should be the eradication of physically/mentally/socially damaging behaviors. If this involves replacing a very destructive substance with a much more benign one, then what’s the problem. many in the treatment industry need to stop playing the guilt card!!

  4. One thing that the analogy doesn’t capture is that recovery involves healing from the various non-physiological aspects of addiction. Replacement drugs address physiological dependence, but not addiction.

    Bill White’s recent monograph uses a quote from a methadone advocate to makethis point:

    “Patients, former patients, staff, policy makers, and the public expect the methadone treatment program to treat addiction. While that is a reasonable expectation, it is not what Opioid Treatment Programs (OTPs) do. OTPs treat opiate dependence, and they do it very well. Most patients on an adequate dose of methadone do not continue to use opiates. However, opiate addiction is more than dependence on opiates; it is dependence combined with a series of behaviors. OTPs (with a few exceptions) do not treat the behavioral aspects of addiction. The behavioral aspects are not treated by a medication but rather by counseling, therapy, peer recovery supports, and 12-step groups. As long as well-intentioned people go around saying that “methadone is recovery,” it is going to continue to be misunderstood. Methadone is a medication, a tool, even a pathway, but it is not recovery. Recovery is a way of living one’s life. It doesn’t come in a bottle”

    http://www.dawnfarm.org/recovery-oriented-methadone-maintenance-part-5

    • Adi Jaffe says:

      Jason, while there might be a number of behaviors associated with addiction (it would be great if you would list those you are referring to), I think most people would agree that taking drugs is the number one behavior that defines addiction. In fact, according to the DSM, it’s the only one that matters. Replacement therapies do a GREAT job of reducing that specific behavior and without that first step, I don’t know of a good way to get at the rest of the problems many addicts present with.

      By the way, replacement therapy specifically DOES NOT address physiological dependence, which is one of the main reasons people are against it. It leaves patients still dependent on opiates and we hear the horrible withdrawal stories some patients tell on that front.

      While I respect Bill White and his work, a monograph is essentially a nice word for a long essay which means that the work is driven by opinions, well-informed as they may be. Again, since I believe that the main aspect to “treating addiction” is reducing drug taking and eliminating compulsive drug-taking, I would consider replacement therapies as indeed treating addiction IN SPITE of opiate dependence. In addition, as you can tell from some of the other comments on this post and from my illustration, often times replacement therapy does bring about concomitant changes in just those behaviors I think you’re referring to (and there’s a slew of peer-reviewed research to support that statement).

      Of course the medication is not recovery. Since “recovery” is considered a way of life, neither are therapists (or therapy), 12 step groups, the best designed CBT manual, or any of the other tools we have at our disposal. As I point out at the end of the article, each of these is merely a tool that should be considered, when appropriate, to help bring about recovery from addiction. Recovery doesn’t come in a bottle a big book or anything other than the actions of individuals but each of these can, for some people, facilitate a better way of life,

  5. LIttle ALEX says:

    LOOK I’M NO SCIENTIST,BEHAVIORAL THERAPIST,ADDICTION SPECIALIST,OR EVEN THE LOWEST ON THE TOTEM,OR SHOULD I SAY HIGHEST(THOSE WHO STUDY NATIVE AMERICAN CULTURES WILL UNDERSTAND WHAT I MEAN)CHEMICAL DEPENDENCY COUNSELOR. I AM THOUGH A WOMAN WITH AN IQ OF 152,WHO WAS RAISED WITH MY TWO OLDER SISTERS AS AAU SANCTIONED JR.OLYMPIAN TRACK AND FIELD ATHLETES. WHERE MY FATHER WAS TRAINING US TO BECOME OLYMPIC GOLD MEDALISTS IN THE 1984 SUMMER GAMES IN LOS ANGELES.PERSONALLY I WANTED A CAREER IN FORENSIC SCIENCE.INSTEAD SINCE THE AGE OF 13 I HAVE BEEN AN ALCOHOLIC,PILL POPPER,USER OF EVERY AND ANY DRUG,EVERY WHICH WAY UNTIL 1980 WHEN AT 14 YEARS OLD I FOUND MY NICHE IN LIFE,WHICH WOULD BECOME A THIRTY FIVE YEAR ADDICTION VIA INTRAVENOUS USE OF HEROIN AND COCAINE. ALL THOUGH I SWITCHED USING THE COCAINE IN 1990,AND STARTED MY TWENTY (BAR)A DAY 0F 2 MILLIGRAM BENZO USE! NOW AT THE AGE OF 48 I AM STILL TAKING MY METHADONE, FOR WHICH I ALSO STARTED AT AGE 16,OFF AND ON, AND WHILE BACK THEN IT REALLY ONLY WORKED AS A BAND-AID,ALSO TRYING BUPRENORPHINE/NALTRAXONE STUDIES IN 1997, BECAUSE FOR WHATEVER REASON I WAS NOT YET READY TO BECOME CLEAN! IN FACT I LOVE OPIATES! I LOVE BENZODIAZAPAN, BUT I DO NOT HAVE THE FINANCIAL RESOURSES, NOR AM I FAMOUS! I DON’T CARE, NOR LISTEN TO PEOPLE WHO HAVE NEVER EVER BEEN ADDICTED TO CHOCOLATE LET ALONE A DRUG LIKE HEROIN! I ALSO DO NOT BELIEVE IN RAPID DETOX,DRUG INTERVENTIONS AND NA.WHILE THE LATTER MAY WORK FOR MOST TO ME IT IS ANOTHER FORM OF A CRUTCH. I CALL IT NARCOTIC ATTRACTION, BECAUSE EVERY MEETING THAT I HAVE EVER ATTENDED LEFT ME WANTING TO CALL UP MY LAST DRUG DEALER…. OH WAIT THAT WAS ME. I ALWAYS SAID THAT AA,CA,NA SHOULD BE MORE PRO ACTIVE. THEN PEOPLE SITTING IN A CIRCLE TALKING ABOUT ALL OF THEIR DRUG BATTLES. PRETTY MUCH THE SAME ONES THAT I FOUGHT, AND MOST WERE SO DESTRUCTIVE I’M AMAZED THAT I ACTUALLY LIVED THROUGH THEM! NOW I KNOW THAT FOR SOME PEOPLE THOSE PROGRAMS AND METHODS WERE A GODSEND,BUT THE BIG AND REAL QUESTION IS…… WILL THEY STAY CLEAN FOR THE REST OF THEIR LIVES? JUST AS ANYONE CAN START OUT AS SAINT,BECOME A SINNER, AND BACK AGAIN! HOW MANY TIMES WILL THEY RELAPSE? WILL A MAN WHO CHEATS ON HIS WIFE NEVER DO IT AGAIN ETC.? I HAVE NO FRIGGIN IDEA! I CAN ONLY ANSWER FOR MYSELF. METHADONE HAS BEEN THE BEST IN REGARDS TO TREATMENT FOR MYSELF. WHILE INGESTING MY 220 MILLIGRAMS OF LIQUID METHADONE,I SAY THAT I AM NO LONGER USING ILLEGAL DRUGS NOR AM I ABUSING LEGAL ONES. EVEN THOUGH I AM PRESCRIBED TO TAKE 4 MILLIGRAMS OF ALPRAZOLAM A DAY FOR MY SEVERE PTSD,OCD,PANIC,AND SEVERE ANXIETY ATTACKS. I WAS A PEDESTRIAN WHO WAS HIT BY A CAR BACK IN 2003. I LIVE IN SEVERE CHRONIC PAIN EVERY MINUTE OF EVERYDAY! THE PEOPLE WHO KNOW ME WITNESS THAT THE AMOUNT OF METHADONE AND ALPRAZOLAM NEITHER REDUCES MY PAIN, NOR DO EITHER DRUGS GIVE ME ANY SORT OF HIGH. IN FACT I NOT ONLY FEEL THEM,BUT EVERYDAY I HAVE NEW PAINS RUNNING THROUGH MY BODY SUCH AS,CARPAL,
    TUNNEL,BURSITIS,CELLULITUS,TENDONITIS,AND OSTEOARTHRITIS! THE PRESCRIBED DRUGS THAT I TAKE ARE THERE TO GIVE ME SOME SEMBLANCE OF A NORMAL LIFE,BUT YET EVEN THOUGH I HAVE BEEN CLEAN(AT LEAST TO ME) METHADONE TREATS ADDICTS, AND DOES NOT TREAT FOR PAIN IE. HERE IS WHERE MY DICHOTOMY LIES.I NEED TO GET ONTO A PAIN CLINIC THAT WILL PRESCRIBE ME THE EXACT SAME AMOUNT OF METHADONE IN PILL FORM FOR WHICH I CURRENTLY TAKE DAILY IN LIQUID FORM. I COULD GO INTO A PROPOSAL ON WHY I SHOULD BE SWITCHED TO A PAIN CLINIC,BUT THIS IS NOT THE FORUM. STATISTICS DO SHOW THAT A DRUG ADDICT PAST,PRESENT,AND FUTURE????? ARE ALWAYS TRYING TO GET HIGH,AS MOST ADDICTS DO,BUT I HAVE NEVER BEEN A TYPICAL ADDICT. DRUGS NEVER DEFINED WHO I WAS,OR WHO I AM AS A HUMAN BEING. REGARDLESS I HAVE HAD TO LIVE MY WHOLE LIFE WITH THE SKEPTICS ASSUMING MY ULTERIOR MOTIVES,AND HIDDEN AGENDAS!I WILL ALWAYS BE STIGMATIZED,OSTRACIZED BECAUSE OF MY PAST DRUG USE! BUT I AM JUST LOOKING FOR A BETTER WAY TO ABSORB METHADONE AND FIND A BETTER WAY TO CONSUME IT WHILE DEALING WITH MY CHRONIC PAIN! A DRUG ADDICT DOESN’T NEED AN EXCUSE TO USE,AND WE ALL KNOW THAT AS HARD AS IT IS TO GET CLEAN. IT IS WAY HARDER TO STAY CLEAN! IN FACT FOR THE LAST 8 YEARS WHILE LIVING IN SHRONIC PAIN, AND ESPECIALLY HAVING TO DEAL WITH MY CHILHOOD DAYS, AND ALL THE COLATERAL DAMAGE THAT I EXPERIENCED THROUGHOUT MY ADDICTION, AND NOW HAVING TO MENTALLY GO THROUGH ALL OF THE REGRESSION.HOW NOW THAT MY MIND IS LUCID,AND WHEN I REFLECT, SOMETIMES I CAN’T BELIEVE THAT I HAVEN’T RELAPSED,OR SLIT MY WRISTS! ONE WOULD THINK THAT I SURELY WOULD BE A CANDIDATE FOR RELAPSE, BUT LOOK AT WHAT I HAVE PROVEN! MY STATISTICS,MY FACTS,MY LIFE! MAYBE THE SEATTLE TIMES SHOULD HAVE CONSULTED ME WHEN WRITING THEIR INVESTIGATIVE REPORT ON “METHADONE” FOR WHICH THEY WON A PULITZER PRIZE FOR. MAYBE OUR LIVES ARE PRE- DESTINED. WE ARE DOING EXACTLY WHAT WE ARE MEANT TO BE,FREEWILL AND ALL. IF WE MAKE A CHOICE WHETHER POSITIVE,OR NEGATIVE. WHO’S TO SAY THAT CHOICE WAS PART OF THE BLUEPRINT OF OUR LIVES! I DON’T FUCKIN KNOW? JUST AS I CAN’T SAY THAT I WON’T EVER RELAPSE, BUT I SAY TO MYSELF THAT I WOULD RATHER TAKE MY OWN LIFE THEN DELVE BACK INTO THE LIFE OF A “JUNKIE”! I COULD GO ON AND ON, BLAH, BLAH, BLAH,BUT WHO CARES! IT IS WHAT IT IS,AND IT SHALL BE! NES PA, CEST LA VIE! IF YOU REALLY THINK ABOUT IT. ISN’T THIS JUST OUR OWN PRIVATE HEAVEN OR HELL HERE ON EARTH! WHATEVER HAPPENS IS,WAS MEANT TO BE?????

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