More than one million Americans are chronically opiate dependant. Most go without meaningful treatment or recovery counseling. While existing treatment systems reduce harm, they still leave the majority of opiate users outside the mainstream of professional treatment, and without the benefits enjoyed by those in recovery from other addictive substances. Clients are often reluctant to use current Narcotic Treatment Programs. Methadone clinics can only treat a fraction of the addicted and are not often structured to provide extensive counseling. In a revolutionary development, opiate substitution therapy combined with professional counseling is becoming available through private physician's offices, narcotic treatment centers, and outpatient recovery centers.

On October 8, 2002, the Food and Drug Administration (FDA) announced approval of Subutex and Suboxone, Buprenorphine-based medications, to be prescribed by physicians in their offices and clinics for the treatment of opiate dependence (FDA-CDER, 2002). This is to be combined with the physicians' newly certified capacity to refer to immediate and long-term relapse prevention counseling as part of a whole recovery plan. We had the opportunity at the Matrix Institute on Addictions to be a test site for the counseling groups and a medication clinic prior to the FDA approval. We observed opiate-addicted clients over a six-month to one-year period as they worked to halt relapse using buprenorphine replacement therapy.

Buprenorphine is an opioid medication used in the treatment of pain. It is a long-acting medication that binds tightly to the endorphin receptors, blocking the effects of subsequently administered opioids. Buprenorphine's potential clinical advantage over full agonists (substitute opiates) such as Methadone is due to its relatively low level of physical dependence, mild withdrawal, and high safety profile. It combines these characteristics without producing a strong narcotic high (Reckitt Benckiser, 2002). Such attributes give Buprenorphine a "partial agonist" activity to be used in the treatment of opiate withdrawal, pain relief, and to reduce physiological cravings. It is distinctly different from Methadone, which as a full agonist, is more highly addictive, with a more prolonged withdrawal period. It is hoped that private treatment with Buprenorphine will draw patients into treatment at a younger age and earlier in their addiction.

Subutex is Buprenorphine and is used in the early withdrawal phase. The medication Suboxone combines Naloxone, an opiate antagonist, and Buprenorphine. Taken as a sublingual tablet, Suboxone can help prevent cravings, but has the advantage of producing a "ceiling effect." As a partial agonist, dosing above this ceiling does not produce an increased opiate effect, as it could with a full agonist such as Morphine, Oxycontin, or Methadone. This ceiling also limits such overdose symptoms as the suppression of respiration. Overdose dangers in which the physician must still guard against include the additional use of benzodiazapines, alcohol, or other opiates. This is one example of the necessary physician/counselor collaboration. Suboxone also has a low potential for intravenous abuse. If abused by crushing and injecting, the Naloxone, the antagonist medication, will activate and precipitate withdrawal, stopping the effects of opioids. This effect was designed to discourage possible street diversion and abuse.

Detoxing from Suboxone use results in a less severe and lengthy withdrawal than is seen with full agonists. This makes it more realistic and safer for some in recovery from heroin addiction to make the transition from opioid maintenance to naltrexone treatment, or to complete opioid abstinence. A heroin dependent patient will now be able to receive opioid medication for detoxification or maintenance in a physician's office. The time between dosing for Suboxone can also be lengthened - ending the need for every-day clinic dosing. Subutex and Suboxone are less tightly controlled than methadone because they have a lower potential for abuse and are less dangerous in an overdose (FDA, 2002). Buprenorphine allows for treatment in a variety of settings and physicians may write a prescription for a take-home supply, making it less disruptive to a patient's other responsibilities. This allows more time in the client's recovery schedule to focus on achieving sobriety, while lessening time seeking and waiting for medication. Physicians will be certified and able to refer their patients immediately to addiction treatment providers. In this integrated treatment delivery system the role of recovery counselors will be pivotal. There will be a new opportunity to work with physicians to engage and retain outpatient opiate clients. Full pharmaceutical and physicians' certification information is available through the Substance Abuse and Mental Health Services Administration, (http://buprenorphine.samhsa.gov/) and through the manufacturer, Reckitt Benckiser, (http:www.suboxone.com/).

According to Dr. Walter Ling, MD, director of the Integrated Substance Abuse Programs at the University of Los Angeles of California, Los Angeles, "We preach that addiction is a disease, but we continue to treat it as a sin. Now, for the first time, we can get serious about treating it as a real disease and treat those addicted like real patients. It will take time to become part of more generalized medical practice. Physicians' attitudes will change slowly"(Elliot, 2002). Dr. Ling is a Principal Investigator in our study.

During the study funded by the National Institute on Drug Abuse, patients in the earliest stages of recovery from intravenous heroin were prescribed Subutex, then Suboxone, and received structured counseling in their relapse prevention effort. Our study clients, who constituted a wide demographic range and differing histories, but with long periods of heroin use, worked on maintaining abstinence. We worked with 95 clients. Subutex and Suboxone have been studied in over 2,000 patients prior to FDA approval, and the drugs were found to be safe and effective treatments for opiate dependence, with less risk of psychological or physical dependence than Schedule II drugs such as Methadone. It is therefore listed as a Schedule III drug to intentionally expand treatment (FDA, 2002; NAADAC, 2002; Curley, 2002). One application for Subutex may be as a first treatment of choice, as clients are evaluated and sequenced onto longer-term maintenance, possibly with Methadone, or detoxed completely.

Clients reported a lowered intensity of physical drug cravings and an increased ability to concentrate on learning and practicing cognitive-behavioral relapse prevention skills. Many also demonstrated improvement in un-learning old behavior patterns and conditioned assumptions. Some had previous experience with Methadone and preferred not to return to Methadone maintenance due to their perception that it suppressed or flattened normal emotional responses and had a long withdrawal period. The clients worked to separate the internal emotional and physical pressures to relapse from the external triggers that had in the past been associated with opiates. For over one year, data was kept on their progress, and on exactly what relapse prevention skills they each found vital to avoid relapse to heroin. The study compared the use of the Matrix Model, an educational, manualized skill development program, to office-based counseling by a physician and to counseling within a Methadone program. This paper describes the Matrix Model delivery arm of the study.
Often a new medication commands all the attention of clients and their families, in the familiar "silver bullet" mistake of wishing for a simple cure. Instead, time and care was invested in the behavioral and personal work of the clients. We observed with the clients how these two treatments could integrate into one. It was part of the group culture that recovery planning was equal in importance to the medication treatment itself. The physician and the counselor regularly consulted, and the clients and counselor noted what the medication would not assist with and was ultimately the responsibility of the client to resolve. The physicians and counselor reviewed the progress of each client and were free to suggest concerns to each other, such as any use of secondary drugs.

The frequency of meetings, and medication dosage were set depending on the medical assessment, and the schedule established between the client, counselor, and physician. Regular weekly group times were available to all. The Institute also sees private clients. This advantage allowed our opiate clients to participate as part of a diverse group. The Suboxone contributed greater security while the clients acted on altering or limiting the influence of emotional and social cues that had been connected to the use of heroin. Without the immediate relapse pressure of withdrawal illness, the clients could identify those old habits that were still connected to the addiction, and discover and practice new actions to diminish these relapse risks.

Retention in treatment was a top priority and our three different settings demonstrated differing retention rates. Setting clearly influenced retention, and retention in treatment influenced sobriety. According to the first published statistics, "...at 12 weeks, 39 percent remained in treatment at the specialists office, 38 percent at the Narcotic Treatment Program (Methadone Clinic), and 59 percent at the outpatient clinic (Matrix). At 24 weeks, 30 percent remained in treatment at the specialist's office, 14 percent at the NTP, and 48 percent at the outpatient clinic. In addition, there was a trend for the proportion of opiate-free urines provided at the outpatient clinic to be higher than those at either of the other sites" (Cunningham-Rathner et al., 2002). Findings suggest that setting will likely influence the outcome of treatment with buprenorphine. While successful implementation is possible in various settings, the degree of success depends on adaptation of the setting to the needs of the patients. It appears that non-pharmacological psychosocial treatment offers some advantage. The full statistics will be published later this year, (and noted in Counselor Magazine's "In Brief" section when available) however, it can be observed that throughout the study, the clients with the greatest access to cognitive behavioral counseling most successfully developed the skills to maintain sobriety and stay in treatment.

In the approach these clients took, the aim was to reassert the role of the decision-making center of the brain, the cerebral cortex, while de-emphasizing the mid-brain which is more vulnerable to chemically reinforced behaviors. The client needs time and practice to shift away from conditioned habits - this is supported by a relaxed, and pro-active atmosphere. Matrix incorporates various disciplines in a setting where discussions of specific relapse-prone situations can take place. The topics have been empirically developed and the relapse prevention skills are discussed in a format that is pre-set, yet still flexible enough to adapt to individual planning sessions. The program is guided by the written topics, scheduling of personal activities, and the development of new responses to old situations. The length of the group meetings varied, averaging an hour, with the total visit to Matrix, including a private discussion with the study physician, often filling more than two hours. The clients developed a menu of behavioral options. The very fact that there is a wide range of options on how to react in any given situation gives hope to clients that their own choices and abilities can create change. It is understood that the addictive impulses and thoughts of drug use will continue, even though clients have clearly stated they want to be free from addiction. This is to be expected and prepared for in advance by education and planning. Clients are taught to recognize the "trigger-thought-craving-use" pattern and learn new ways to break up this relapse sequence before an actual relapse occurs. Direct client feedback on the Buprenorphine medication was that it assisted in maintaining objectivity, as well as the motivation to pursue the relapse prevention work without becoming emotionally overwhelmed.

The groups emphasized the ability to reorganize common situations and deal with dilemmas with less stressful emotional reactions. These are not process groups. The tone is confidential and confident, not emotional or probing. The topics discussed in each group relate to this resourceful decision-making and how each client can apply it in the many small and large crises they have to overcome without drug use.

In this study the effective contribution of the medication did not stand alone, but instead functioned in a synergy with counseling. The Suboxone eased cravings, allowing creative, personal relapse prevention skills to be learned and practiced over time. Clients made gains in confidence, frustration tolerance, health, time sober, and the ability to sustain these gains. A new, private setting without stigma appeared to help clients enter treatment, and find individualized plans for the future - whether with opiate substitution maintenance or becoming completely opiate free.

The clients took significant actions, beyond abstaining from heroin and secondary substances, to change other life situations and to alter their beliefs about those situations. When, after establishing early sobriety, a relapse or even a "near relapse" occurred, clients practiced their ability to trace the specific chain of events, feelings, thoughts, and visual triggers that had preceded the risk of relapse. They were then able to increasingly plan ahead to interrupt these recognized patterns when they began to repeat. Medication was clearly understood to be just the first step in a recovery to be won in these real and unavoidable settings. The clients reported that this work was more achievable due to the Buprenorphine lessening physical cravings, but not impairing energy or positive emotions, while they focused on reducing old relapse cues. Clients who did not establish periods of sobriety were referred to more intense treatment.

The clients who most effectively used the medication were those who also directed their attention toward seeing and solving dangerous situational crises as rapidly as they came up. They did not trust the medication alone, but combined it with careful, real-life changes. Topics discussed in the groups included: Hour by Hour Scheduling - Mooring Lines - Recognizing Addict Behaviors - Obsessing - Halting Emotional Building - Be Smart; Not Strong - Food, Sleep, Exercise, Work - Recognizing and Reducing Stress - and a basic "Brain Model" education about the structures and biochemistry involved in conditioned habits and the extinguishing of habitual behaviors. The gradual lessening of addictive impulses and urges was clearly noted and tracked by clients (Obert et al., 2000). Clients found certain subjects particularly useful:

They discovered that stopping the use of marijuana or alcohol resulted in fewer, more easily manageable opiate relapse urges, and that smoking cigarettes prompted cravings. Recovery felt more secure after quitting smoking.

Clients' regularity of attendance was strongly correlated with sobriety. Attendance was encouraged by a positive atmosphere and an open respect for the difficulty of change. Clients' ambivalence was viewed as normal, rather than being framed as "denial." Motivation was seen as a byproduct of an effective client-therapist relationship, rather than a trait required of the client. Combining the physician visit with the group counseling in the same clinic helped clients stay in treatment.

Most clients could quickly identify the "Dangerous Emotions" that were most likely to become relapse triggers. Sadness and loss, or memory of a loss, were powerful cues. Long-term heroin use may create lasting changes in brain chemistry, permanently impairing the ability to manage these emotions. Clients observed that they could develop the ability to cope with some emotional stress, limit the relapse risks, and maintain sobriety even while suffering unavoidable sadness or loss - the medication support was noted as extremely important at these times.

"Thought-stopping" to halt drug thoughts combined visualization, a pre-set ability to choose a thought, and simple physical interventions to divert emotional building or addictive thinking. Emotions are respected, but the aim is not to battle emotions or to experience an emotional catharsis. The aim is to separate old behaviors from their emotional triggers by planned actions, and allow the old habits to gradually diminish.

Most clients had past experience attending social support groups, which they felt had low expectations for those in heroin recovery. They resented being exposed to many stories of past drug use because they found that graphic drug use stories were relapse triggers. Shopping for new social support groups that were free of these problems was a common need. Traditional "Alcoholics Anonymous" was sometimes a solution for leaving heroin references behind.

Heroin abstinent clients found it critical to halt obsessing about the past, to separate "shame" from reasonable unhappiness, and to not over-anticipate negative events. Taking care of what was happening right now helped them to stay proud of their freedom from heroin. Staying in the "here and now" required a new understanding that the brain was undergoing physical healing from the changes caused by past drug use, and that irritability, anger, and insecurity may actually be a part of the healing process.

Some clients dealt with loss and mourning in their intimate relationships, while also protecting their own early recovery. They balanced their vulnerabilities with work and the development of their personal creative talents and futures. This was consciously done in order to establish a new balance. Shifts in this balance called for subtlety more than emotional breakthroughs. Emotional strength is good, but the motto of the group was that it is better to be smart than strong. They did not always solve external problems, but they mentally separated those problems from the old relapse justifications. They valued the advantage of the medication, but only as one tool to protect them. Retention in treatment was strengthened by the clients' own proof to themselves that they could manage one small difficulty at a time, share this progress, and get feedback. This may be expected as "Treatment As Usual" in recovery from other substances, such as alcohol, or stimulants, but it was a new experience for the opiate clients. The pharmacotherapy of Buprenorphine helped to stabilize the early recovery period, making new self-management skills, usually more closely associated with recovery from other substances possible.

The introduction of Subutex and Suboxone into the treatment system will forever change our understanding of heroin treatment options. Lives will surely be saved by reducing overdose and slowing diseases related to needle use. It may become increasingly realistic for the clients, private physicians and counselors to work toward sobriety as a team. The challenge will be to successfully integrate this new medication into a system of care that also delivers the necessary non-pharmacological treatment.

Most Americans addicted to heroin or other opiates remain untreated and there are many barriers to treatment. The client's own ambivalence may prompt a focus on the most problematic aspects of sobriety. Methadone maintenance may be ideal for some, but not all. By recognizing that opiate-addicted individuals have individual treatment needs, the process of "matching" patients to the most appropriate treatment can be seen as a way to improve outcomes. The approval of Suboxone opioid substitution therapy provides addiction counselors and addiction medicine specialists with an opportunity to work together to coordinate new treatment for those who have had few options in the past. The former heroin addict can finally join the mainstream of those in recovery through the use of new treatment plans that coordinate effective medication with professional counseling.

Jeanne Obert, LMFT, MSM, is a co-founder and the Executive Director of Matrix Institute on Addictions, a non-profit company affiliated with the UCLA Integrated Substance Abuse Programs in Los Angeles, CA.

Readers have left 2 comments.

 2. Untitled
sarah, Unregistered

This seems like a great thing... Now the question is, "how do we make it available to the people who need it the most, and may not be able to afford it?".

 Posted 2007-12-09 22:20:23

 1. Untitled
FullmoonFvr, Unregistered

Great article. Maybe it will help decrease the wait for addicts to get
treatment and facilitate recovery.

 Posted 2007-10-16 05:28:11

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