Intrinsic health risks, social losses, stigmatization, multiple areas of serious dysfunction and impairment to overall well-being are all consequences of opioid dependence. The treatment of this serious illness is available and necessary if any of these afflicted life domains are to enjoy improvement.
Therefore, the principal objectives of treating and rehabilitating people with opioid dependence are to: ameliorate or even alleviate associated morbidity and mortality resulting from infectious diseases, cardiac sequalae, liver disease, STD's and traumatic fractures; improve psychological and overall physical health; diminish criminal behavior; facilitate workforce reintegration; educate the patient and families, if available, about germane aspects of the illness and enhance social function and self-worth. The ultimate goal of opioid dependence treatment is to create a drug free state.
This ideal may not be readily achievable for opiate addicted patients until much care and treatment are rendered. There is a necessity for multiple treatment options due to the fact that no single treatment is universally effective for every patient with opioid dependence. There are several pharmacological approaches and also very imperative psychological treatment modalities. The first step in treatment requires a form of detoxification.
This can readily be done in uncomplicated cases as an outpatient. Rehabilitation treatment must accompany this first phase or the likelihood of relapse is far more common than not. An abstinence focused treatment and substitution based maintenance approach are the most effective methods to systematically treat opioid dependence.
Treatment of opioid addiction should utilize the development of established care plans for each of the individual's needs, abuse patterns and risk factors. Criteria driven treatment has been suggested as a guideline- not standard of care intended- to streamline and focus any treatment method.
The American Society of Addiction Medicine (ASAM) has suggested the following criteria to consider for patient selection and treatment
option appropriateness:
• Acute intoxication and/or withdrawal potential.
• Biomedical conditions and complications.
• Emotional, behavioral or cognitive conditions and complications.
• Readiness to change.
• Relapse, continued use or continued problem potential.
• Recovery and living environment
The American Psychiatric Association (APA) has an established guideline which identifies the following three treatment modalities to be effective methods to treat and manage opioid dependence and withdrawal.
1Opioid substitution with methadone or bupremorphine followed by a general taper.
2Abrupt opioid discontinuation with the use of clonidine to suppress withdrawal symptoms.
3Clomidine-maltrexone detoxification.
Additionally, the APA strongly urges that psychological treatments accompany any of the above three biological modalities. These types of treatment are clearly essential as part of a comprehensive approach for an opioid abstinent successful, sustainable treatment outcome. The more sought after form of treatment in recent years (since about 2000), is an office based opioid treatment using Buprenorphine and Naloxone replacement therapy (Suboxone). The office-based treatment evolved after the passage of the Drug Addiction Treatment Act of 2000. It allowed physicians to use some Schedule III-IV drugs such as buprenorphine in combination with other agents. Physicians must be certified through specific training as required by the DEA which includes a special second DEA number beginning with an "X" once all the requisite training and waivers have been met. At the outset of this office-based treatment initiative, a maximum of 30 patients could be treated by a duly certified physician. In 2007 that maximum was raised to 100 patients.
There are three contiguous phases of office-based treatment utilizing Suboxone.
• First, the induction phase. This phase requires the perspective dependent patient to present already in at least mild to moderate withdrawal. That means that the patient must be opioid abstinent for at least 6 or even up to 24 hours. There are two major scales that physicians can use to objectify and help quantify the patient's withdrawal status. They are The Clinical Opiate Withdrawal Scale (COWS) or the Adjective Rating Scale for Withdrawal (ARSW). These scales assist with supporting clinical observations regarding safely determining the dosage of Suboxone needed on an individual basis in order to prevent further withdrawal discomforts, minimize any potential adverse effects and reduce cravings.
• Once the induction phase is completed as evidenced by patients no longer experiencing any withdrawal symptoms, phase II- or stabilization phase begins. This phase requires both frequent follow up evaluations by the prescribing physician and the concomitant psychosocial treatments. It is focused on dosage adjustments as needed to continue to reduce cravings and still minimize any adverse reactions. The duration of the second phase is typically one to three months.
• The third phase has the longest duration. It is the maintenance phase and provides pharmacological and psychosocial treatments to sustain the gains obtained in the prior two phases. The goals are medication monitoring, adjustment as needed and eventual tapering and discontinuation where possible. This phase may last typically between six months to more than two years. The duration of Suboxone treatment should be tailored to the individual's interest and willingness to maintain wellness without opiates, adequate attention being paid to levels of stability, functional capacities in all life domains i.e.: work, relationships, family, life, academics, and general behavior.
Other parameters to include in durational assessment include the patient's prior response to treatment if treatment has been offered before and the chronicity and extent of the dependence itself.
The frequency of follow up visits will be determined by patient response to treatment, consistent negative urine dry screens, adherence to prescribed amounts of medication and ongoing psychosocial or support treatments. Afterwards, intervals of every 30 days can be applied.
Office based treatment for opioid dependence has become a very positive method to address this serious need. Increasing the access, improving the safety and efficacy of the treatment and emphasizing a more comprehensive approach to individualized needs serves to enhance the quality of care, destigmatize the patient's experience, offer more hope with integrity and provide for a realizable opioid free life.
Please contact our office directly at (609) 484-0770 to schedule an evaluation for our Comprehensive Suboxone Program utilizing both modalities simultaneously and confidentially. Being alone in all this is scary and unnecessary.
Charles E Meusburger, MD is a licensed, board certified diplomat of Psychiatry & Neurology, specializing in Adult and Adolescent Psychiatry, Addiction Psychiatry, Effective Talking Therapies, and Medication Evaluation Management, practicing for over 20 Years with experience helping people to make their lives better and happier. Please feel free to contact us at SNJ Psychiatry.com [http://snjpsychiatry.com], and call us at 609-484-0770 and come in for an appointment if we can help you with any of life's demands.
Therefore, the principal objectives of treating and rehabilitating people with opioid dependence are to: ameliorate or even alleviate associated morbidity and mortality resulting from infectious diseases, cardiac sequalae, liver disease, STD's and traumatic fractures; improve psychological and overall physical health; diminish criminal behavior; facilitate workforce reintegration; educate the patient and families, if available, about germane aspects of the illness and enhance social function and self-worth. The ultimate goal of opioid dependence treatment is to create a drug free state.
This ideal may not be readily achievable for opiate addicted patients until much care and treatment are rendered. There is a necessity for multiple treatment options due to the fact that no single treatment is universally effective for every patient with opioid dependence. There are several pharmacological approaches and also very imperative psychological treatment modalities. The first step in treatment requires a form of detoxification.
This can readily be done in uncomplicated cases as an outpatient. Rehabilitation treatment must accompany this first phase or the likelihood of relapse is far more common than not. An abstinence focused treatment and substitution based maintenance approach are the most effective methods to systematically treat opioid dependence.
Treatment of opioid addiction should utilize the development of established care plans for each of the individual's needs, abuse patterns and risk factors. Criteria driven treatment has been suggested as a guideline- not standard of care intended- to streamline and focus any treatment method.
The American Society of Addiction Medicine (ASAM) has suggested the following criteria to consider for patient selection and treatment
option appropriateness:
• Acute intoxication and/or withdrawal potential.
• Biomedical conditions and complications.
• Emotional, behavioral or cognitive conditions and complications.
• Readiness to change.
• Relapse, continued use or continued problem potential.
• Recovery and living environment
The American Psychiatric Association (APA) has an established guideline which identifies the following three treatment modalities to be effective methods to treat and manage opioid dependence and withdrawal.
1Opioid substitution with methadone or bupremorphine followed by a general taper.
2Abrupt opioid discontinuation with the use of clonidine to suppress withdrawal symptoms.
3Clomidine-maltrexone detoxification.
Additionally, the APA strongly urges that psychological treatments accompany any of the above three biological modalities. These types of treatment are clearly essential as part of a comprehensive approach for an opioid abstinent successful, sustainable treatment outcome. The more sought after form of treatment in recent years (since about 2000), is an office based opioid treatment using Buprenorphine and Naloxone replacement therapy (Suboxone). The office-based treatment evolved after the passage of the Drug Addiction Treatment Act of 2000. It allowed physicians to use some Schedule III-IV drugs such as buprenorphine in combination with other agents. Physicians must be certified through specific training as required by the DEA which includes a special second DEA number beginning with an "X" once all the requisite training and waivers have been met. At the outset of this office-based treatment initiative, a maximum of 30 patients could be treated by a duly certified physician. In 2007 that maximum was raised to 100 patients.
There are three contiguous phases of office-based treatment utilizing Suboxone.
• First, the induction phase. This phase requires the perspective dependent patient to present already in at least mild to moderate withdrawal. That means that the patient must be opioid abstinent for at least 6 or even up to 24 hours. There are two major scales that physicians can use to objectify and help quantify the patient's withdrawal status. They are The Clinical Opiate Withdrawal Scale (COWS) or the Adjective Rating Scale for Withdrawal (ARSW). These scales assist with supporting clinical observations regarding safely determining the dosage of Suboxone needed on an individual basis in order to prevent further withdrawal discomforts, minimize any potential adverse effects and reduce cravings.
• Once the induction phase is completed as evidenced by patients no longer experiencing any withdrawal symptoms, phase II- or stabilization phase begins. This phase requires both frequent follow up evaluations by the prescribing physician and the concomitant psychosocial treatments. It is focused on dosage adjustments as needed to continue to reduce cravings and still minimize any adverse reactions. The duration of the second phase is typically one to three months.
• The third phase has the longest duration. It is the maintenance phase and provides pharmacological and psychosocial treatments to sustain the gains obtained in the prior two phases. The goals are medication monitoring, adjustment as needed and eventual tapering and discontinuation where possible. This phase may last typically between six months to more than two years. The duration of Suboxone treatment should be tailored to the individual's interest and willingness to maintain wellness without opiates, adequate attention being paid to levels of stability, functional capacities in all life domains i.e.: work, relationships, family, life, academics, and general behavior.
Other parameters to include in durational assessment include the patient's prior response to treatment if treatment has been offered before and the chronicity and extent of the dependence itself.
The frequency of follow up visits will be determined by patient response to treatment, consistent negative urine dry screens, adherence to prescribed amounts of medication and ongoing psychosocial or support treatments. Afterwards, intervals of every 30 days can be applied.
Office based treatment for opioid dependence has become a very positive method to address this serious need. Increasing the access, improving the safety and efficacy of the treatment and emphasizing a more comprehensive approach to individualized needs serves to enhance the quality of care, destigmatize the patient's experience, offer more hope with integrity and provide for a realizable opioid free life.
Please contact our office directly at (609) 484-0770 to schedule an evaluation for our Comprehensive Suboxone Program utilizing both modalities simultaneously and confidentially. Being alone in all this is scary and unnecessary.
Charles E Meusburger, MD is a licensed, board certified diplomat of Psychiatry & Neurology, specializing in Adult and Adolescent Psychiatry, Addiction Psychiatry, Effective Talking Therapies, and Medication Evaluation Management, practicing for over 20 Years with experience helping people to make their lives better and happier. Please feel free to contact us at SNJ Psychiatry.com [http://snjpsychiatry.com], and call us at 609-484-0770 and come in for an appointment if we can help you with any of life's demands.
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