MEDICATION ASSISTED TREATMENT?
- What is it?
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Individuals who want to stop their illicit drug use can find it very difficult. Their need to satisfy cravings or avoid withdrawal can be so intense that they feel desperate and overwhelmed. At the right dose, and with psychosocial intervention (e.g., counseling) medication assisted treatment can suppress opioid withdrawal symptoms and suppress cravings to help individuals continue treatment and avoid illicit opioid use.
The APT Foundation currently offers two forms of medication assisted treatment for opioid dependence: (1) methadone and (2) buprenorphine (Suboxone®). Both of these longer acting opiate medications work by stabilizing the brain chemistry, preventing withdrawal, and reducing craving. When properly prescribed and taken, people do not experience a high from these medications. For people with sever opioid dependence, these medications may be prescribed for a period of years to help stabilize and support the person making changes in other life areas.
- Understanding Opioid Dependence
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What are opioids?
Opioids are drugs that work in the body the way opium does. Some are made directly from opium (for example, heroin, morphine, and codeine), while others are man-made but similar chemically to opium (for example, the painkillers oxycodone, hydrocodone, and fentanyl, better known by such brand names as Oxycontin®, Vicodin®, Percocet® and Actiq®).
What is opioid dependence (also called addiction)?
Dependence on opioids has been defined as a long-term brain disease by the World Health Organization (WHO) and the National Institute on Drug Abuse (NIDA). It is a treatable medical condition that is caused by changes in the chemistry of the brain that occur as a result of the use of opioids. It may have started with medicine that your doctor prescribed for serious pain or with recreational drug use with prescription pain medicine or heroin.
What are common characteristics of opioid dependence?
An individual who shows 3 or more of the following behaviors over a 12-month period is most likely opioid-dependent:
- Opioid tolerance
- Withdrawal symptoms occur when opioids are not used
- Taking other drugs to help relieve the withdrawal symptoms
- Taking larger amounts of opioids than planned and for longer periods of time
- Persistent desire to or unsuccessful attempts to quit
- Spending a lot of time and effort to obtain, use, and recover from opioid use
- Giving up or reducing social or recreational activities; missing work
- Continued use of opioids, regardless of negative consequences
What actually happens in the brain?
There is a part of the brain that we refer to as the "reward circuit." This is the area of the brain that, among other things, regulates pain and pleasure. Basic life functions—such as eating—stimulate receptors in the brain's "reward circuit" to release dopamine, a chemical that produces an intensely pleasurable feeling known as "euphoria."
It doesn't take long to learn that certain activities will be "rewarded"—that is, that they will prompt dopamine release and pleasurable sensation. This positive reinforcement is the brain's way of encouraging behavior important for survival.
The ability to activate the reward circuit accounts for some drugs being viewed as potentially addictive. Opioids are among those drugs capable of activating the reward circuit to release dopamine and reinforce drug-taking behavior. Activating the reward circuit, together with the changes in the structure and functioning of the brain, have several powerful results.
One result of this euphoria is that drug-taking behavior is rewarded, thereby increasing the chances that the behavior will be repeated.
A second result of this reward is that the brain begins to think drug-taking is actually necessary for survival. To the brain, just the fact that an activity is rewarded at all means that activity must be important for survival.
A third result is that, by the time an individual develops opioid dependence, his or her brain no longer functions normally without opioids.
A fourth result is that opioid-dependence can impair the mechanism by which information from certain areas of the brain—namely, those involved with judgment and caution—is received. Additionally, the motivation to obtain opioids may come from:
- Physical pain and discomfort caused by withdrawal symptoms
- Increasing anxiety due to powerful, unsatisfied opioid cravings
- Stress resulting from the brain's fear that the current lack of opioids presents a threat to its survival
Taken together, all of these results help explain the behaviors associated with opioid dependence.
What is the role of medicine in treatment?
Medicine (Buprenorphine and Methadone) is important for managing both the short- and the long-term effects of opioid dependence. Over the short term, medication can help to relieve the opioid cravings and withdrawal symptoms that occur when use of opioids is discontinued. Medication can be important over the long term, as the individual may need ongoing medication to support their continued recovery.
APT Foundation currently offers two forms of medication assisted treatments for opioid dependence: 1) Methadone and 2) Buprenorphine. Both of these longer-acting opiate medications work by stabilizing the brain chemistry, preventing withdrawal, and reducing cravings. When properly prescribed and taken, people do not experience a high from these medications or if they were to use other opiates. For people with severe opiate addiction, these medications may be prescribed for a period of years to help stabilize and support the individual making changes in other life areas (work, relationships, legal, medical).
Many experts believe that trying to treat severe opiate addiction without one of these medications can be dangerous because of the risk of overdose death, criminal offending, and infectious diseases from the use of street opiates. The APT Methadone and Buprenorphine treatment programs provide outpatient services that include regular (daily, weekly, or monthly depending on the individual) medication dispensing, individual and group counseling, as well as psychiatric, and medical services.
What is the purpose of treatment?
The Methadone and Buprenorphine assisted treatment programs at the APT Foundation provide opiate replacement therapies to individuals who are opioid dependent. The goals of these treatments are to stabilize individuals, help promote recovery from dependence, and improve life functioning.
How do I get into treatment at APT Foundation?
Treatment services are available for adults 18 years or older who are physically dependent on opiates. Sometimes adolescents can be treated with special approval. All individuals seeking treatment at one of our programs are first evaluated at the APT Access Center, which serves as the front door to the Foundation’s various treatment programs and services for people affected by substance use.
People with concerns or issues related to substance use can be evaluated Monday through Friday. Brief screenings can be conducted over the phone (203-781-4357) or by coming to the Access Center at 1 Long Wharf from 7:30AM to 12 Noon. No appointment is necessary. All evaluations involve a confidential 1:1 meeting with a counselor. This can last between 30 minutes to 2 hours depending on the type of services that may be indicated. Concerned family members or other service providers interested in referring someone may call to get information about different options.
What are my counseling options ?
Counseling or psychosocial therapy can be very helpful to almost anyone who is dependent on opioids. The APT Foundation offers the following counseling options:
Individual, or one-on-one counseling -- This is generally considered the best setting for addressing confidential issues.
Group therapy-- Many individuals find group therapy to be particularly effective for treatment of opioid dependence because it provides a support network that they would otherwise lack. Benefits of group therapy include:
- Peer support and acceptance
- Real-world examples of people experiencing recovery
- Positive feedback
The APT Foundation understands that people with substance abuse problems differ in how motivated or ready they are to receive help from other people. Rather than force people to commit to a strict schedule of services, we allow people to receive treatment at their own pace. We do this by offering many “drop-in groups” and encourage clients to participate in as many as they can. To remain active in treatment, a client must attend at least one group per month. We never believe that this is enough for recovery from addiction. However, recovery is a life-long process and sometimes commitment to change takes time to develop. Staff always hopes that people will attend several groups each week. Some of the groups offered may include motivational enhancement, coping skills, relapse prevention, parenting, 12 step education, anger management, vocational planning, relaxation, women’s issues, and men’s issues.
What are triggers?
In addition to functioning as a reward, dopamine is also the brain's way of ensuring that the experience itself will not be easily forgotten. Dopamine release activates the areas of the brain involved in memory formation to record details about the environment where the event occurred.
Which details the brain chooses to record can range from the obvious (where the incident occurred, who was there) to the obscure (a billboard passed on the way, the temperature outside). There is no way to know ahead of time what details the brain has stored. But whatever they were, when those circumstances are encountered in the future, they will trigger memories of the good feelings produced by dopamine, and, often, a desire to recreate that experience. The technical term for these memories is "conditioned associations," but most people familiar with opioid dependence refer to them as "triggers"
What are the keys to successful treatment?
According to the National Institute on Drug Abuse (NIDA) and the Center for Substance Abuse Treatment (CSAT), substance dependence treatment is typically more effective when:
- You remain in treatment for an adequate period of timeYou engage in counseling and other behavioral therapies
- You find a counselor or therapist with whom you can develop a strong therapeutic relationship
- You engage in services that help you take care of multiple needs. For instance, if you have another medical or psychological condition, you receive treatment for that as well. It could also mean that you have services that help you with employment or housing, as needed
- Your progress is monitored by your treatment provider, through the use of urine drug screens and check-ups
- You understand what it means that substance dependence is a "chronic illness" and not something that just goes away after a short treatment
What makes achieving success more difficult?
According to the National Institute on Drug Abuse and the Center for Substance Abuse Treatment, substance dependence treatment is typically less effective when:
- You use other substances
- You end treatment too soon
- There is other substance use in your home
- You have other medical or psychological issues that aren't being treated
Does relapse to drug abuse mean treatment has failed?
Treatment of chronic diseases involves changing deeply imbedded behaviors, and relapse does not have to mean treatment failure. The chronic nature of the disease means that relapsing to drug use can occur. Relapse indicates the need for treatment to be reinstated or adjusted to a more intensive level of care until the individual is again stable and drug-free.
Science has taught us that stress, cues linked to the drug experience (e.g., people, places, things, mood), and exposure to drugs, are the most common triggers for relapse, so strategies need to be developed to help minimize or avoid these triggers. Counseling and group therapy are strongly recommended and provided at APT Foundation to help develop these strategies.
- What is methadone?
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How long does it take methadone to work?
What is Methadone Maintenance Treatment (MMT)?
What is the length of methadone maintenance treatment?
Does relapse to drug abuse mean treatment has failed?
What is methadone?
Methadone is a synthetic agent that works by "occupying" the brain receptor sites affected by
heroin and other opiates. Methadone:
o blocks the euphoric and sedating effects of heroin and other opiates;
o relieves the craving for heroin and other opiates that is a major factor in relapse;
o relieves symptoms associated with withdrawal from heroin and other opiates;
o does not cause euphoria or intoxication itself (with stable dosing), thus allowing a
o person to work and participate in society;
o is excreted slowly so it can be taken only once a day.How does methadone work?
Methadone is a long-acting opioid medication used (in conjunction with counseling and other
services) to treat individuals addicted to short-acting opioid drugs.Taken orally once a day, methadone suppresses opioid withdrawal for between 24 and 36
hours; it reduces the cravings; and it blocks the high from opiates. Because it does not provide
the euphoric rush of short-acting opioid drugs, methadone patients do not experience the
extreme highs and lows associated with illicit use.Because methadone is effective at eliminating withdrawal symptoms, it is also used to detoxify
people currently dependent on opiates.What is Methadone Maintenance Treatment (MMT)?
Methadone Maintenance Treatment (MMT) is an outpatient treatment program in which
people currently dependent on opiates receive a daily dose of methadone, with counseling and
other comprehensive social and rehabilitation services.Treatment services are available for adults 18 years or older who are physically dependent on
opiates. All individuals must be willing to come to the program for medication on a daily basis
and attend weekly group counseling to be eligible for continued treatment.All individuals seeking treatment in our methadone program are first evaluated at the Access
Center, which serves as the front door to the APT Foundation's various treatment programs and
services for people affected by substance use.What is the length of methadone maintenance treatment?
The length of methadone maintenance treatment varies from individual to individual and is
contingent each person's unique treatment needs.Is methadone safe?
Methadone is a rigorously well-tested medication that is safe and efficacious for the treatment
of opioid withdrawal and dependence. For more than 30 years, this synthetic narcotic has been
used to treat opioid dependence.There are more positive research findings about Methadone than for any other form of
effective treatment for drug addiction. This research consistently shows two things.First, methadone is very effective when it is taken daily, for an extended period of time, and
in an appropriate amount (daily dose). Although a few people may do well with a very low
dose for a short period of time, this is not true for most patients. Research has found that
methadone doses below 70 milligrams taken for less than 6 months do not work well for most
patients.Second, methadone is very safe when taken as prescribed by a physician under the supervision
of a nurse. The risk of an addicted patient overdosing on methadone is extremely low in
comparison to heroin. Also, there are many myths on the street about negative side effects of
methadone that are not true.Does relapse to drug abuse mean treatment has failed?
Treatment of chronic diseases involves changing deeply imbedded behaviors, and relapse does
not have to mean treatment failure. The chronic nature of the disease means that relapsing to
drug use can occur. Relapse indicates the need for treatment to be re-instated or adjusted to a
more intensive level of care until the individual is again stable and drug-free.Science has taught us that stress, cues linked to the drug experience (e.g., people, places,
things, mood), and exposure to drugs, are the most common triggers for relapse, so strategies
need to be developed to help minimize or avoid these triggers. Counseling and group therapy
are strongly recommended and provided at APT Foundation to help develop these strategies. - What is Buprenorphine?
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What is Buprenorphine (Suboxone®) treatment?
How is Buprenorphine (Suboxone®) helpful?
How does Buprenorphine (Suboxone®)work?
How long does it take for the Buprenorphine (Suboxone®) to work?
Understanding the stages of Buprenorphine (Suboxone®)treatment
How long will I stay on Buprenorphine (Suboxone®)?
Is Buprenorphine (Suboxone®) safe?
Does relapse to drug abuse mean treatment has failed?
What is Buprenorphine (Suboxone®) treatment?
What is Buprenorphine (Suboxone®) treatment?
Buprenorphine (Suboxone®) is a form of medication-assisted treatment for opioid dependence. Treatment usually begins in a doctor's office.Buprenorphine (Suboxone®) is a small tablet that is placed under the tongue. As it dissolves, it is absorbed into the bloodstream. A short time after the first dose—about 30 to 60 minutes—the doctor will check to see how well Buprenorphine (Suboxone®) is controlling withdrawal symptoms. If necessary, he/she may adjust the dose. When he/she has determined a dose that is right for the patient, a prescription will written, so the patient can begin to take the prescribed does of Buprenorphine (Suboxone®) at home.
At this time, the doctor will also discuss initiating counseling as part of treatment. When Buprenorphine (Suboxone®) medication-assisted treatment is combined with counseling, the likelihood of success is increased. With counseling, the patient can learn how to recognize events that can trigger the use of illicit opioids; learn ways to cope with events or social situations associated with past drug use; and learn skills that can help them recognize triggers that can stimulate cravings, to prevent relapse.
How is Buprenorphine (Suboxone®) helpful?
A number of clinical trials have established that, at appropriate doses, Buprenorphine (Suboxone®) can help patients stay in treatment and reduce the use of other opioids by:- suppressing withdrawal symptoms
- reducing cravings
How does Buprenorphine (Suboxone®) work?
In order to have an effect, opioids must first attach to opioid receptors in the central nervous system. When a full opioid agonist, such as opium, oxycodone, hydrocodone, morphine, or heroin binds to those receptors, it produces the full opioid effect, including feelings of euphoria, or being "high." It also causes painful withdrawal symptoms once the opioid has left the receptors.Buprenorphine—the active ingredient in Suboxone®—works by binding strongly to those same opioid receptors. When taken as prescribed, Buprenorphine (Suboxone®) binds strongly to opioid receptors and blocks the binding of other opioids. It can also suppress withdrawal symptoms and reduce cravings. This can help people remain in treatment and help reduce or stop the misuse of illicit opioids.
How long does it take for the Buprenorphine (Suboxone®) to work?
At the time treatment begins, patients can begin to feel some relief within 20 minutes of the first dose, although the full effects take about an hour and a half (100 minutes), at which point the patient’s symptoms should be re-assessed. Depending on the extent to which the first Buprenorphine (Suboxone®) dose suppressed the patient’s symptoms, the doctor may decide to give the patient an additional dose.Understanding the stages of Buprenorphine (Suboxone®) treatment
1. Induction
You will be asked to come to your first doctor’s appointment in a moderate state of withdrawal. Being in this state is vital to having Buprenorphine (Suboxone®) work well. The opioid drug you have been misusing needs to be free from the receptors in your brain so that the medication can bind to them. The doctor will give you your first dose of the medication, which can be adjusted if you are still not feeling well.When you are ready to leave the office, the doctor will give you instructions and a prescription that will last until your next appointment. The doctor will also discuss counseling services, since adding counseling to treatment with medication has been shown to bring better results. At APT, we strongly recommend at least weekly group counseling, and all individuals must attend at least one counseling meeting each month to be eligible for continued medication.
2. Stabilization & Maintenance
During the Stabilization & Maintenance phase, the doctor will work with you to regularly monitor your treatment progress, adjusting doses if necessary, and focusing on your progress in counseling, trigger management, and relapse prevention.3. Medical Withdrawal
If you and the doctor agree that the time is right for Medical Withdrawal, the doctor will slowly taper down the your dose of Buprenorphine (Suboxone®), taking care to minimize withdrawal symptoms or cravings. If you feel at risk for relapse during a taper, you can be re-stabilized and continue maintenance for as long as needed. Some individuals remain at Step 2, staying in the Stabilization & Maintenance phase. If necessary, patients can restart treatment with Buprenorphine (Suboxone®)Am I eligible for treatment?
Treatment services are available for adults 18 years or older who are physically dependent on opiates. Sometimes adolescents can be treated with special approval. All individuals seeking admission into our Buprenorphine (Suboxone®) treatment program are first evaluated at the Access Center, which serves as the front door to the APT Foundation’s various treatment programs and services for people affected by substance use.How long will I stay on Buprenorphine (Suboxone®)?
The length of your Buprenorphine (Suboxone®) treatment depends on what your doctor, you, and your counselor or therapist decides is best for your treatment needs.The role of Buprenorphine (Suboxone®) is to help patients stay in treatment and reduce illicit opioid use. It's important to remember that the decision to be on medication-assisted treatment is often based on whether someone's symptoms (in this case, cravings and compulsive drug use) are likely to return if the medication is stopped, as well as whether the person in treatment is likely to resume misusing illicit opioids.
Although short-term treatment may be an effective option for some, for others it may not allow enough time to address the psychological and behavioral aspects of their condition, or to reduce illicit opioid use. The chance of relapsing can be higher with short-term treatment. In general, suppressing cravings for illicit opioids with Buprenorphine (Suboxone®), together with counseling and behavioral modification, for as long as necessary, offers the best likelihood for treatment success.
Is Buprenorphine® (Suboxone®) safe ?
There is less research on Buprenorphine because it has not been available as long as other forms of medication assisted treatment, such as Methadone. However, the research does suggests that it is very effective and safe and may be more appropriate for patients with somewhat less severe opiate addiction histories.Does relapse to drug abuse mean treatment has failed?
Treatment of chronic diseases involves changing deeply imbedded behaviors, and relapse does not have to mean treatment failure. The chronic nature of the disease means that relapsing to drug use can occur. Relapse indicates the need for treatment to be re-instated or adjusted to a more intensive level of care until the individual is again stable and drug-free.Science has taught us that stress, cues linked to the drug experience (e.g., people, places, things, mood), and exposure to illicit drugs, are the most common triggers for relapse, so strategies need to be developed to help minimize or avoid these triggers. Counseling and group therapy are strongly recommended and provided at APT Foundation to help develop these strategies.
- Overdose Prevention
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- Overdose is a preventable cause of death in the majority of cases because it usually:
- Happens to experienced users.
- Happens over 1-2 hours, not instantly.
- Is witnessed by other users or others in the users social network.
- Can be treated effectively with naloxone (Narcan®).
What is an Overdose?
What are risk factors for overdose?
What does an overdose look like?
What to do.
What NOT to do if someone overdoses.
What is naloxone (Narcan®)?
How can I become trained in Overdose Prevention?
What is an Overdose?
Overdose (OD) happens when a toxic amount of a drug, or combination of drugs overwhelms the body. Heroinand other downers affect the body’s central nervous system, which slows breathing, blood pressure, and heart rate, and in turn reduces body temperature. In an opiate overdose, the breathing slows to the point of respiratory arrest where the lack of oxygen to the brain leads to the loss of consciousness, coma, or death.
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What are risk factors for overdose?
Mixing Drugs (poly-substance use). Drugs taken together can interact in ways that increase their overall effect. Using drugs that have the same effects on the body can be deadly. Such combinations include cocaine with other stimulants like speed and ecstasy, or when people mix heroin and/or alcohol with benzodiazepines such as Klonopin®, Valium®, and Xanax®. Most fatal overdoses are the result of poly-drug use.
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Tolerance (your body’s ability to process a certain amount of a drug). Tolerance develops over time, so the amount of a drug a long-time user needs to feel the drug’s effects is a lot greater than a newer user. Tolerance also wavers depending on several factors including, weight, size, illness, stress, compromised immune system (from HIV, AIDS, hepatitis for example), and age. Your tolerance actually decreases over time, which is why there are more deaths among older users. Most importantly, tolerance can decrease rapidly when someone has taken a break from using a substance whether intentionally while in drug treatment or on methadone detox, or unintentionally while in jail or the hospital. Research has also shown that tolerance is effected when a person uses drugs in a new or unfamiliar environment, and therefore at a higher risk for overdose.
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Quality (how pure a drug is). The content and purity of street drugs is always unpredictable. They are often “cut” with other drugs or materials that can be dangerous. You can’t tell how pure your drugs are from looking at it, and purity levels are always changing, which means you can use a drug that is a lot stronger than what you are used to and put yourself at risk of an overdose.
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Using Alone. While using alone is not necessarily a cause of overdose, it increases the chance of fatally overdosing because there is no one there to call for help or take care of you if you go out. Many fatal overdoses have occurred behind closed or locked doors where the victims could not be found and no one was there to intervene
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Changes in your health. A serious illness including AIDS, liver disease, diabetes and heart disease, or a recent illness or weight loss can decrease your tolerance and lead to an increase risk of OD. Maintain your health by eating, sleeping and seeking medical care when you don’t feel well.
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What does an overdose look like?
Users can check in with each other for responsiveness. Overdose is more likely 1-2 hours after using rather than just after injection.
Signs:
- May be awake, but unable to talk
- Body is very limp
- Face is very pale or clammy
- Fingernails and lips turn blue or purple
- Breathing is very slow and shallow, erratic, or has stopped
- Pulse (heartbeat) is slow, erratic, or not there at all
- Choking sounds, or a gurgling noise
- Vomiting
- Loss of consciousness
- Unresponsive to outside stimulus
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What to do.
- Lay the person on their side
- CALL 911. Many of us are afraid to call 911 when someone we know ODs. You may have had a bad experience with paramedics, or heard stories about people being arrested when the police came. Nevertheless, calling 911 may be the only way to save the person's life.
- Tell the dispatcher that the person is unconscious and not breathing or turning blue.
- Tell them exactly where you and the person is, the address and room number. If you are outside, give them the nearest street intersection and a landmark, as much information as possible to help them get to you. If you're squatting, send someone out to the street to wait for the ambulance.
- Once the paramedics arrive, tell them as much as you know about what drugs the person was using.
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What NOT to do if someone overdoses.
Do Not put the person in an ice cold bath, it could put them into shock, or they could drown. If they are still breathing, you can put them under a cool shower to wake them, but stay with them and keep the water away from their nose and mouth.
Do Not inject them with salt water or milk, it won’t revive them and in the time it takes to find a vein you could be rescue breathing or trying to wake them up
Do Not inject someone overdosing on heroin with speed or cocaine. It is not a good use of time and can make them worse. It is one more drug their body has to deal with.
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What is naloxone (Narcan®)?
Naloxone, commonly called Narcan®, is a non-scheduled prescription medication used to counter the effects of an opiate (i.e. heroin or morphine) overdose. It has been the standard care for emergency departments and paramedics for the past few decades. It works by binding to the opioid receptor in the brain and reversing the depression of the central nervous and respiratory systems. It “tricks” the brain into thinking there are no opiates in the body.
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If someone is overdosing on an opiate, administering naloxone can speed up their breathing and temporarily bring them out of an overdose. Remember naloxone only works on opiates, not speed or benzodiazepines like Klonopin® or Valium®.
Naloxone sends people into immediate withdrawal, which can be really uncomfortable. That person may want use again because they cannot feel the opiates in their system, but using more can send them back into an overdose. Reassure them that in about 45 minutes their sick feeling will go away. Do not let them use again and keep an eye on them because once the naloxone wears off they are still at risk of overdosing.
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How can I become trained in Overdose Prevention (OD)?
Overdose Prevention (OD) Training is taking place in all APT programs and is one of the Core Education groups made available to all APT clients. OD prevention training is available in both group and individual format.
After participation in an overdose prevention-training, clients may choose to meet with an APT Foundation staff physician to receive an overdose prevention kit. Contact the APT Foundation to find out more about overdose prevention and how to respond to an overdose.
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