Drug addiction recovery…

Dr. Michael J. O’Connell, PainCare, New Hampshire, noted that for the past decade, prescription drug addiction has gradually surpassed addiction to street drugs e.g. heroin and cocaine.  Opioids, benzodiazepines, and amphetamine like drugs (Adderal, Ritalin) are not surprisingly the most heavily abused, since they are all obtainable by prescription, and mimic the two infamous street drugs, heroin and cocaine.  Also not surprising, patients who are prescribed opioids for legitimate pain and drugs for ADD while not generally the addicts, may be frequent ‘unintentional suppliers’ to addicts.  Lost or stolen prescriptions, “borrowed” drugs, and faked prescriptions largely account for the availability of such drugs.

Doctor shopping, despite PMPs (prescription monitoring programs), is still rampant.  Why has there been such a swing to prescription drugs?  It is always about economics; the more available, the less expensive.  Prescription drugs have been increasingly available due to willingness among primary care providers to aggressively treat chronic and cancer pain.  This has lead to cheaper prescription drugs.  However, in response to such competition, heroin and cocaine have been selling for less now than five years ago, and both are more potent, so the pendulum may swing back to increased use of the classic street drugs soon.

Treatment of these various addictions is typically difficult, marred by frequent relapses, and a comprehensive approach usually mandatory for greatest success.  For uppers (cocaine and amphetamines), there are no proven effective pharmacologic approaches.  For benzos, there are essentially none.  For opioids, methadone and buprenorphine they are specific and effective, with a plethora of scientific studies to validate use.  So, what is the difference between these two chemicals?

Methadone is frequently called a “replacement” or ‘maintenance’ drug, since it is itself a potent agonist opioid.  It is also capable of giving a “high” especially if combined with other drugs or if injected.  Methadone can only be prescribed for addiction if doled out daily in a methadone clinic, usually in liquid form.  This is safer in one respect, in that the patient is given a known allotted dose, ingests the dose under the watchful eye of the medical assistant, has urine frequently monitored, and has access to various counseling and cognitive treatments on site.  Methadone clinics are less safe in one important respect however, and that is that the entire dose of methadone is delivered once daily (methadone does have a long half life).  Patients often times report feeling very high and somnolent for hours after, and most drive themselves home.  Yikes!  Lastly, methadone usually is continued ad infinitum, with most clinics making the calculation that it is better to have an opioid addict on methadone without cravings, than roaming the street and committing crimes to support the habit.

Buprenorphine does not cause a significant ‘high’ because it is a weak partial agonist.  But it very effectively mitigates cravings due to a high affinity for the opioid receptors.  Furthermore, it exhibits a ‘ceiling effect’ whereby further increases in dose (even massive overdoses) do not result in either respiratory depression, significant or prolonged somnolence, or other opioid side effects.  The biggest advantage of buprenorphne however, is that eventual wean and discontinuation is not only possible, but considered desirable and “the goal” of buprenorphine treatment.  There is little stigma attached to the use of buprenorphine as it is prescribed in the privacy of a doctor’s office and the prescription is filled at the pharmacy.  One disadvantage of buprenorphine is its street value.  Why would this be?  Heroin addicts, or those hooked on large doses of potent opids (pills), can often allay their severe withdrawal symptoms with buprenorphine, if their drug of choice is unavailable or too expensive for their drug “budgets.”