Replacement therapy as addiction treatment – Why it makes sense

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…

Alcohol, benzos, and opiates – Withdrawal that might kill you

Along with teaching and telling stories, part of my goal here at All About Addiction is to get important information out to those who can benefit from it.

Most drug users who quit drug use “cold turkey” have to go through withdrawal of some sort. Withdrawal is never comfortable, but sometimes it can actually be dangerous. The list below outlines some drugs that should NEVER be quit suddenly without medical supervision. This is the reason why some rehab treatment is preceded by a medical detox period lasting anywhere from 2 days to a week or more.

Which withdrawals can actually kill?

  1. Alcohol – Yes, after long term use, withdrawal from alcohol can kill. Alcohol withdrawal syndrome can take on mild, moderate, or severe forms. If while withdrawing from alcohol a person develops a fever, extreme nausea, diarrhea, or DT (delirium tremens), they need to be rushed to see a doctor as soon as possible. In fact, alcohol withdrawal after heavy, chronic use is best managed under the care of a doctor or a professional medical detox unit. By using medications that relieve withdrawal symptoms, these professionals can essentially eliminate any of these risks.
  2. Benzodiazepines – Benzos were introduced as a replacement to barbiturates that were causing common overdose cases, many of which resulted in death. Nevertheless, withdrawal from extended use of benzodiaepines can kill. Whether Xanax (alprazolam), Ativan (lorazepam), Valium (diazepam) or other variations, long term use of Benzodiazepines requires medical supervision to be completed successfully with minimal side-effects and risk to the patient. Normally, the withdrawal process is managed by slowly reducing the dose and transferring the patient from a slow acting, to a long acting, form of the drug. Still, full resolution of benzodiazepine withdrawal syndrome can take up to 6 months (or even longer).
  3. Opiates – Many people are surprised to learn that in most cases, withdrawal from many opiates is not deadly. Still there are some very important exceptions. Methadone, a long-acting opiate often prescribed as a replacement for heroin can cause death during withdrawal if it’s consumed in high enough doses for a long enough period. The debate of whether the state should be prescribing something like this should be saved for a later date. It is one of the better ways of getting people off of heroin, though obviously, all it does is replace dependence on one substance with another, more manageable one. Also, some of the recently popular methods of rapid-detox from heroin addiction can themselves cause death, and many other negative side-effects. Overall, I would recommend checking in with a physician and conducting opiate withdrawal in a controlled setting. Withdrawal under Suboxone or Subutex can be far less horrific.

Much of the danger in withdrawal from all of these drugs has to do with the body’s response to the extreme changes in the chemical processes going on in the brain and the rest of the body. Alcohol, Benzos, and Opiates interference with the GABA system, the body’s most common downregulator.

Withdrawal from these drugs is like trying to turn the heat up in a cold house with a broken thermostat and an out of control heater – It won’t always lead to disaster, but it’s a bad idea.

The withdrawal danger summary

That’s pretty much it. “Cold Turkey” withdrawal from cocaine, marijuana, crystal meth, ecstasy, GHB (never mix GHB with alcohol though!!!), and many other recreationally used drugs will not lead to death in the vast majority of cases. While it may make you uncomfortable, and you may feel moody, constipated, dehydrated, hungry or nauseous, and a whole slew of other symptoms, the chances of someone actually dying from withdrawal are very small.

If you have any more specific questions regarding your case though, don’t shy from asking me!