By Tina Stec, MD, MPH
and Bizhiki Wellness Center
Drug and alcohol use are big problems in the US and at Lac Courte Oreilles reservation. We have seen way too many people die from drug overdose or from the effects of alcohol. Most people who have a problem with drugs or alcohol at some point know they need to get sober. When someone decides to get sober, the big question is, how should they do it? Do they need medication to get and stay sober? To understand the role medications have in helping with sobriety, we need to first talk about addiction. Addiction is not the result of a lack of will power. It is a brain disease which affects the reward circuitry in the brain. What works for one person to get sober may not work for another for various reasons. One person may have a mild addiction, whereas another may have a severe addiction. Also coping skills matter. Some people learned some healthy coping skills growing up, and others did not. Sober support matters too. One person may have lots of sober support but another person may be surrounded by those who use. So, the severity of the addiction, the coping skills of the person and the sober support all work together to determine whether a person can just stop using “on their own” or whether they need help with treatment, meetings and/or medications. There are medications to help with cravings for drugs or alcohol, and these are the medications we will discuss today. Most people with addiction also suffer from other mental health issues such as depression, PTSD, anxiety or trouble sleeping. There are medications that can help with these mental health conditions and these should also be addressed to maximize chances of staying sober, and these are reasons to also see a doctor when trying to get sober. MAT
The medications that have evidence to help stop drug or alcohol use specifically are called Medication Assisted Treatment, or MAT. The medications considered a part of MAT are medications that are trying to help with withdrawal and cravings for the drug or alcohol. The most common MAT medications are Suboxone, methadone and Vivitrol. Suboxone and methadone are used for opioid use disorder (heroin or pain pill addiction), and Vivitrol is used for alcohol and opioid use disorder. Before we discuss these medications let’s review what opioids are: An opioid is a drug that stimulates the opioid receptors in our brain. Opioids are pain pills like oxycodone, hydrocodone, percocet, heroin and fentanyl. Kratom also stimulates the opioid receptors.
Suboxone is a partial opioid and is used to treat fentanyl, heroin or pain pill addiction. Suboxone is a medication that is taken daily, or can be given as a monthly injection called Sublocade. Suboxone and Sublocade are “partial opioids”, meaning they partially turn on the opioid receptors. Heroin, or oxycodone, or fentanyl fully (100%) turn on the opioid receptor, but suboxone only partially turns on the receptor. Suboxone turns on the opioid receptor enough to take away cravings and withdrawal, but there is a “ceiling effect.” It will not give someone a high when they already have an opioid tolerance (as people do who use heroin) and they will not overdose on suboxone due to this ceiling effect. This ceiling effect makes Suboxone safer than a full opioid. The other benefit of suboxone is that it also blocks the opioid receptor. Suboxone binds more strongly to the receptor than other opioids, such as heroin. So, if someone is taking suboxone and then they use heroin, they will not “feel” the heroin, as it can not get on the receptor since suboxone is blocking it.
Vivitrol is a monthly injection and can be used for alcohol or opioid addiction. Vivitrol works by working as an opioid blocker. Like suboxone, vivitrol will block the opioid receptor if someone uses heroin or other opioids. In the case of alcohol, it is the opioid receptors that make alcohol rewarding and with a lack of reward, the person will not drink, or will stop drinking after a couple drinks. The person who is addicted to heroin or other opioids has to be off all opioids for 7-10 days before Vivitrol can be given. Most people can not stop opioids for 7-10 days so it can be difficult to get people with opioid use disorder on Vivitrol. We can sometimes start it after someone goes to detox or treatment, or after they get out of a prolonged jail stay. Methadone is given for addiction only at methadone clinics. This is not offered at LCO because it requires special licensing, security and staffing. Methadone is a full opioids and 100% turns on the opioids receptor just like heroin or pain pills will. It can be abused and one can get “high” and overdose on it, which is why it is highly regulated and initially given with monitored daily dosing. The closest methadone clinic in the area is in Chippewa Falls. Suboxone (and Sublocade), vivitrol and methadone are all supported by studies to save lives, prevent overdoses, decrease crime and keep people out of jail. The longer people remain on these medications, the better they do. I usually tell people to plan on being on Suboxone or vivitrol for at least a year. It usually takes at least a year to get the mind clear, develop coping skills, change and repair your relationships, have stable housing, and get a job, etc. Basically we want to give people time to “get their ducks in a row” before they come off these medications. Some people will stay on these medications longer, and some may stay on them for many years due to being in a community where there is a lot of drug use and triggers, or having other instability in their lives, or other mental health issues, or lack of coping skills.
Some people may be doing well for over a year but feel happy with where they are that they do not want to “rock the boat” at this time. What they are doing is working and they don’t want that to change. Debunking Myths about Suboxone
There are people out there who think that if someone is on Suboxone, they are not sober. They think that being on Suboxone is just trading one drug for another. However, this is not true.
Addiction is diagnosed by addictive behaviors, and people on Suboxone can stop all addictive behaviors. Suboxone is not making people who are prescribed it high, it is just helping them to feel normal and not have cravings for heroin. This way, they can focus and put their energy towards the things in their life they care about. Most people who want to quit using drugs, just want to be done with it all, and not rely on any medications to stop. This is understandable. The person just wants to be able to move on from their use and not have to take anything to feel ok. They want the drug use to be in the distant past and not be reliant on any substance anymore, like they have been reliant on the drug. The problem is that quitting drugs and alcohol can be very hard to do. With heroin (or other opioids) and alcohol, these can be especially hard as there is physical withdrawal that happens. People will start to feel sick within a day and this can heighten at 3-5 days for heroin, but for both drugs can last weeks. With heroin, many people can make it 2 days without using but can’t take the withdrawal past that time period. The withdrawal feels like they might die. In the case of alcohol withdrawal, people can actually die from the withdrawal. Beyond the first week or two of the physical withdrawal is the cravings that continue even once physical withdrawal is over. The person does not feel right. He feels down, low energy, distracted. Cravings take over. It takes the brain a long time to get back into balance without the drug or alcohol. The person is at risk of relapse. We know that addiction is a chronic and recurring disease, much like diabetes or high blood pressure. These conditions do not usually entirely go away, but can be treated and controlled. A medication to help with addiction should be looked at the same as someone who is taking a medication for diabetes.
Selling Medication We are aware that people will sometimes sell their Suboxone. The people who do this are not serious about staying sober, and at the Recovery Clinic we usually know who are likely doing this due to their continued drug use seen on their drug screens. We give people a little time to sober up and then we will no longer offer Suboxone if we believe they are selling their medication. Most people who are BUYING suboxone are not abusing it, they are usually using it so they do not get sick when they do not have heroin. However the people who are SELLING it are usually doing so to get money to buy drugs, which is not ok. We have a big problem in the LCO Community with people sharing, selling and buying medications on the streets. This has been going on for a long time and with many different medications. Not only is this illegal, but it is contributing to this culture of addiction where
people try to self medicate and think that a pill is the answer to their problem. This has also gotten many people addicted to opioids in this community as most people who use heroin started with pain pills they got either from a doctor or from the streets, and in most young people today they started their use with pills from the streets. Pills on the street get expensive and they need more and more so that is why people start to use heroin.
MAT Helps People Engage in Treatment
Although MAT (medication assisted treatment) is a tool to help people stay sober, they can be essential for some people and is strongly supported by evidence. Through using these medications we can help stabilize people, stop their use, and get them to engage in meetings, groups, therapy, and treatment. Through coping skills, dealing with past trauma, dealing with mental health issues, and getting sober support one learns to stay sober for the long run and the need for the medication diminishes once skills are learned to help one stay sober.
At Bizhiki Wellness Center and the LCO Recovery Clinic(in the Bizhiki Wellness Center) we can help people get and stay sober. We discuss the options and the evidence behind those options. Like anything else in life, a treatment plan to get sober needs to be individualized. We have therapists, AODA counselors, CCS facilitators, a doctor, a nurse practitioner, a nurse, and a medical assistant, among others at Bizhiki. We are here to help those who are ready to get sober with a number of tools and therapies at our disposal, including MAT.