As a nation, we must focus on the treatment and recovery of over 2 million people suffering from opioid use disorder. In this blog post, we’ll look at the options for treatment (detox and medication assisted) and challenges with recovering from opioid dependence. After reading this last of the blog series, you will have a solid understanding of the problem we are facing and the decisions that we need to make as a nation – working collaboratively along with law enforcement and harm reduction; treatment centers and emergency rooms; pharmaceutical companies and community organizations – because in the end, it will require all of us side by side to defeat this crisis.
What does it take to rid an opioid dependent’s system of the very substance they crave? Let’s first consider a scenario where the individual who uses drugs is forced to quit quickly without any medical or pharmaceutical intervention. This is often the way people who are opioid dependent are forced to quit when they are enrolled in mandatory detox programs or incarcerated in most of our nation’s jails.
The withdrawal symptoms grow and change over time. Early symptoms – as early as 12 hours without opioids include watery eyes, runny nose, sweating, anxiety or irritability, poor sleep and muscle pain.
As the withdrawal continues, the symptoms expand to include cramping, diarrhea, vomiting, increased heart rate and blood pressure, restlessness, shakiness, chills, sweating and dilated pupils. (These are the same symptoms that we often see when we use NARCAN as a rescue drug from an overdose.) This phase of withdrawal can last from 4 to 10 days.
While the withdrawal symptoms are rarely life threatening – they are very uncomfortable and often disabling, and many people who use drugs return to opioids because of a desire to stop the withdrawal symptoms. If the individual is using multiple drugs, the cumulative effect of an immediate withdrawal can be even more dramatic.
When detox occurs, the opioid tolerance that had built up in the body is reduced, although the desire for more opioids still exists. When released from mandatory detox programs or incarceration, the individual who used drugs is extremely vulnerable as they have a high risk of relapse and a lowered tolerance meaning they could overdose easily on a level of drug consumption that they were using in the past. In fact, a study showed that “Patients who “successfully” completed inpatient detoxification were more likely than other patients to have died within a year. No patients who failed to complete detoxification died”. In other words, reduced tolerance and mandatory detox alone are not a good combination.
You’ll recall Zach who I introduced in a prior blog who is a recovering opioid user. Zach shared with me that he was once forced into a 28-day detox program in order to keep his living accommodation. Every moment his mind was on the 29th day. When he was released, he immediately went to find his dealer and buy more heroin. Immediately after his detox, Zach was at considerable risk because his tolerance of heroin changed in the 28 days and a dose that used to create a comfortable high could cause an overdose. Fortunately, Zach knew that he needed to be careful with dosing but within days his dependence and tolerance was returning to pre-detox levels.
Beyond the difficult and rarely successful detox we just discussed, many individuals who are opioid dependent can further suffer post-acute withdrawal syndrome (also known as PAWS). PAWS is characterized primarily by physical symptoms including tremors, seizures, autonomic nervous system hyperactivity (sweating, nausea, rapid heart rate) and an intense drug graving. These symptoms can last for several months in people recovering from opioid dependency.
To achieve better success, there are recommendations to leverage medication-assisted treatment along with therapy. This combination has proven successful. The treatment can include partial opioid agonists that replace the heroin and other opioids without the same effect (e.g., methadone and buprenorphine) or complete opioid antagonists (e.g., extended release naloxone). Let’s look at each of these treatments.
Methadone
For years, methadone was the most sought-after treatment. Programs were rare and expensive to get in to. Methadone works by changing how the brain and nervous system respond to pain. As a partial agonist, it blocks the painful withdrawal symptoms while also blocking the high / euphoric effect of opioids. Methadone can be addictive and withdrawal from it takes longer than withdrawal from heroin.
Zach chose to seek out a MAT program that included psychotherapy as well. This combination provides the best chance of success. He was very fortunate to get into a program as the waiting lists are long and the costs seem out of reach when you’re addicted to drugs and are panhandling and hustling daily to fund your drug habit. Another challenge Zach shared was the need to daily go to the treatment facility to take the methadone. It began by trying to find the right dose. Each day the methadone dose was increased until the high from heroin wasn’t felt any longer. The opioid dependent individual is typically encouraged to keep taking heroin as they had in the past until the correct dose of methadone is determined. For months, Zach had to go to the clinic every morning to drink his methadone in the presence of a counsellor. As trust was proven, Zach was able to get enough methadone for a weekly supply and take it at home. This meant he didn’t have to go to the clinic every day. It meant he could see his friend in Philadelphia for a weekend. Imagine the willpower it takes to begin a treatment program that takes over your life. No travel. No oversleeping the clinic’s hours. It’s a huge commitment, but with methadone, he could begin to get his life back – including a place to live on his own.
Buprenorphine
Buprenorphine is also an opioid partial agonist and, like methadone, can create a high on its own, but much less than heroin or other opioids. Unlike methadone treatment, which must be performed in a highly structured clinic, buprenorphine is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in physician offices, increasing treatment access. One of the techniques that make this feasible is the combination of buprenorphine (a partial agonist) with naloxone (an antagonist) in a single film. When taken as directed, the buprenorphine is slowly released into the body which eases cravings and withdrawal symptoms. If it’s mis-used (for example, if you were to inject it to try and get a high from the buprenorphine), the naloxone acts as an antagonist and blocks the high and worsens the withdrawal symptoms. This makes Suboxone tamper-resistant.
The treatment program starts after the opioid dependent individual has stopped taking opioids for at least 12 hours and has started to feel the withdrawal effects.
Naltrexone
Naltrexone is a time release version of naloxone. It’s currently most widely used and marketed as Vivitrol. It’s popular because it is an injection only given once a month. There are several challenges with the effectiveness of a Naltrexone based program. The drug user must be completely through detox before being given Naltrexone. As you might expect, this is not a choice that an opioid dependent individual would likely make, and this is typically used in facilities such as jails where there is often forced detox. Like other MAT programs, it’s effectiveness also requires counselling. The maker of Vivitrol – Alkermes – has made considerable investments in marketing Vivitrol to the point where even the White House’s national strategy to combat the opioid crisis cited “naltrexone treatment” without mentioning other MAT options. While still controversial, it is important to understand how and where it’s best suited.
Scaling Treatment Access
If we consider a need to treat over 2 million people with opioid use disorder, we must be able to scale treatment access and programs very quickly. One of the most interesting models that I’ve seen is Workit Health – workithealth.com. Their stated goal is “Workit Health helps you beat opioid addiction with the best Suboxone doctors and evidence-based online therapy. All in 1-2 hours a week, for a $25 copay with most insurance”. (It still requires a prescription cost for the Suboxone, and if you don’t have insurance, they have variable pricing based on ability to pay.) I spoke to Kali Lux who is their Head of Marketing (and a recovering person who used drugs) to find out more about the program. It begins with an in-person assessment and then both medical treatment and counseling can be completely managed via telemedicine. The program is buprenorphine (Suboxone) based because the medication can be prescribed off-site, unlike methadone, and may offer Vivitrol in the future as well. Workit Health does require technology and internet connectivity, so may not work for some – but the scalable nature of it and the access with no waiting lists makes it a great example of how to build a treatment model that can respond to the crisis. In December, Workit Health became a certified B corporation (B Corps are for-profit companies certified by the nonprofit B Lab to meet rigorous standards of social and environmental performance accountability and transparency). Workit Health also employs a very interesting marketing philosophy. Since both Co-CEOs and much of the team are former opioid dependent individuals now in recovery, they recognize the unique needs of the population they’re dealing with. They understand that waitlists or long intake processes won’t work for people seeking help today and aim to be simple to find and easy to use.
Recovery
After successfully stabilizing in a treatment program, the path to recovery has just begun for most people. For example, Zach required assistance with housing, and finding jobs as an individual recovering from opioid dependency is often difficult because of public records that often include arrests and charges.
Some cities and states (e.g., New Hampshire) have created a “Recovery Friendly Employer” designation. These are employers who understand the challenges of a recovering drug user and recognize the passion they have to do a great job. They tend to always be on time. They are hard working. They are dedicated. They are grateful for the chance to prove themselves.
As this is the last blog in this series, I wanted to share with you two stories of people who are recovering from opioid dependency.
The first is Tracey Helton. Tracey was actually in the HBO documentary “Black Tar Heroin – The Dark End of the Street” that many of you watched after reading my first blog. She has dedicated her life to harm reduction. Among her many accomplishments, she wrote “The Big Fix – Hope After Heroin”. If you have read this blog series, you should absolutely read her first hand perspective. For her 20th anniversary of sobriety, she had a bottle of naloxone tattooed on her arm. She is a speaker, an addiction counsellor and an advocate/role model to many.
The second is Zach. When I first met Zach in New York, he spent hours sharing his story with me. He showed with me an app on his iPhone that tracked how long he’d been clean (2 years, 6 months and 14 days at the time), and the amount of money he’s saved from not shooting up (about $111,000). Zach inspires others through his story. Last week, I received a text from Zach about finding a full bag of heroin on the street. He picked it up, took a photo of it (it was a stamped bag), then ripped it apart and threw it away. THAT is what recovering from opioid dependency looks like!!!
My hope is that through the blogs, you’ve developed a better understanding of the challenges we face as a nation and that you will embrace the challenge of helping so many people who use drugs and have become opioid dependent. As a nation, we can solve this challenge and mitigate the overwhelming crisis we now face. At Medigram we believe that urgent exchange of information about individuals who suffer from opioid use disorder who need timely care is a key to solving this challenge. We look forward to sharing more about that with you in the coming months.
By: Dean Shold VP, Technology at Medigram
Dean Shold is the VP of Technology for Medigram. Before his current role, Dean was the VP of Infrastructure and Chief Technology Officer for Stanford Health Care, and was previously the VP of Global Data Operations for Zephyr Health. With a degree in computing science and a passion for social good, real time data analysis and mobile computing, he brings a unique background and perspective to the healthcare industry. At Medigram, Dean drives enterprise customer complete solution development, implementation, support, and customer success. At Stanford Health Care, he led a global team of 180+ personnel at 24x7 support to 50+ locations including multiple hospitals. He managed the technology and support budgets and built and reorganized teams to drive performance and reliability. He built a command center based on FEMA's (Federal Emergency Management Agency Guidelines) and oversaw data center performance and builds.
Dean also has deep passion for practically addressing the opioid crisis. His interests are in the scientific and the social sides of the opioid crisis bridging the people who use drugs and are opioid dependent with the researcher and the lawmaker. He is fascinated by how the worlds of legal and illegal opioids intertwine and how our societal biases impact treatment and recovery. In his work, he brings a vision of how Health IT can be leveraged to better understand and address the crisis. This includes examining the following key dimensions in addition to Health IT such as fentanyl, naloxone, harm reduction, detox, treatment and recovery.
Outside of the office, Dean also co-founded a non-profit organization to create novel ways to donate to charities. Dean is an instrument rated pilot and avid music lover. He and his wife, Pauline recharge by exploring harm-reduction organizations, the arts, craft beer and music scenes.
Links to check out:
Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study
SAMHSA Opioid Overdose Toolkit
SAMHSA Medication-Assisted Treatment
STAT – Vivitrol offers the fantasy of being drug-free. But that’s not the most important thing in tackling addiction.
The New York Times – Seizing on Opioid Crisis, a Drug Maker Lobbies Hard for Its Product
Workit Health – A Certified B Corporation
New Hampshire’s Recovery Friendly Workplace Initiative
The Big Fix – Hope after Heroin – Tracey Helton Mitchell