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Fact and Fiction for Consideration by Addiction Counselors

It is no surprise that individuals in this country have had major drug problems for many years. The most commonly abused drug changes over time—for example, cocaine was the drug of choice in the 1980s and alcohol continues to be a consistent problem today. It is incumbent upon those of us providing treatment to be as accurate as possible in understanding the issues in order to make a positive change in the lives of the people we treat.

Fact or Fiction: “If people are on methadone or buprenorphine, they are still addicted.”

One of the greatest objections to the use of opioid agonist drugs (i.e., methadone and buprenorphine) is the belief that users are “still addicted.” Using opioid agonist drugs serves to reduce craving and eliminate withdrawal, thereby eliminating addicts’ need to acquire more of the drug to which they were addicted. In the short term, this lessens the need to engage in criminal behavior to acquire opioids and reduce the potential for overdose. Once individuals are stable, they can be employed and involved in prosocial behaviors such as functioning as parents, significant others, and/or community members.

Methadone and buprenorphine, when substituted for illicitly used opioids, continue the physiological dependence, which occurs at a cellular level. It is important to discriminate between physiological dependence and addiction, which is characterized by compulsion, loss of control, and continued use despite adverse consequences and craving. If individuals are abusing neither the antiaddiction drug they were prescribed nor any other nonprescribed drug, they remain physiologically dependent, but not addicted (SAMHSA, 2004), so this is certainly fiction.

Fact or Fiction: “If individuals are on long-term opioid treatment, they will eventually become addicted.”

Using the aforementioned description of addiction, some individuals will become addicted and some will remain physiologically dependent without becoming addicted, so this idea is fiction. However, long-term opioid use is associated with adverse events including opioid overdose (Von Korff, Kolodny, Deyo, Chou, 2011).

Fact or Fiction: “People on MAT should never use a benzodiazepine.”

Central nervous system (CNS) depressant use is not an absolute contraindication for either methadone or buprenorphine, but it is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, antidepressants, or alcohol, so this statement is fact. However, tapering of benzodiazepines in outpatient settings may be attempted in patients without complications of overdose, seizures, or comorbid medical or psychiatric disorders (IRETA, 2013).

Fact or Fiction: “If people are in recovery from addiction to a particular substance and they use cannabis, they will relapse to their original addiction.”

According to an article in USNews.com,

Even if marijuana is not someone’s drug of choice, using cannabis can trigger a relapse. “People are more likely to seek their primary drug or alcohol when they are intoxicated or high,” says Anne Lewis, clinical psychologist and licensed addiction counselor with Indiana University Health. “It lowers your inhibition, so you don’t care. We don’t make good decisions when we’re drunk or high” (Castaneda, 2016).

My clinical experience is that there is difference in people who are in recovery from opioid addiction—as well as those on methadone maintenance—who drink. Those people have a higher likelihood of developing alcoholism (Castaneda, 2016). This statement is fact.

Fact or Fiction: “Patients in treatment who refuse to attend AA or NA are indicating their lack of readiness to change.”

Regardless of the value of Twelve Step recovery groups in attaining and maintaining sobriety, the spiritual element of these programs may make them unacceptable to some patients, so this is fiction. In those cases when patients will not attend, other options like Smart Recovery must be sought. Although I can find no reference to this in the literature, I believe that patients who have an external locus of control (e.g., outer-directed) may find Twelve Step groups more attractive, while individuals who have an internal locus of control (e.g., inner-directed) may find Smart Recovery more attractive because of the absence of spiritual orientation and the reliance on a cognitive-behavioral approach in which they use their own skills.

Fact or Fiction: “Alcoholics Anonymous is the only self-help support group which effectively supports sobriety.”

There are a variety of support groups for people with alcohol problems, so this is fiction. These support groups include Alcoholics Anonymous (AA), which has the most geographically extensive system; Self-Management and Recovery Training (SMART Recovery); Moderation Management (MM), the website of which states that it is not the right approach for people who have serious alcohol problems; Secular Organizations for Sobriety (SOS); Women for Sobriety (WFS); and Christian-themed recovery groups such as Alcoholics Victorious, Celebrate Recovery, and others. There is no current data about which is more effective, and effectiveness may be a function of the match between the group approach and the needs and attitudes of the individuals (“Alcohol recovery,” 2018).

Fact or Fiction: “If someone is on an antiaddiction drug, they should be ready to stop using it in about six months.”

Patients on antiaddiction drugs such as methadone, buprenorphine, or Vivitrol should continue taking it to the point of stability, reduced chances for relapse, and until patients and their prescribers jointly decide that it is time to discontinue the use of the drug, which makes this statement fiction. Some pharmaceutical manufacturers of these drugs will recommend a minimum length of time for them to be effective, but not a maximum time (SAMHSA, 2018).

Fact or Fiction: “Methadone, buprenorphine, and Vivitrol: One is more effective than the others.”

An opioid agonist is a drug that activates the opioid or “mu” receptors on nerve cells in the brain. A full agonist (methadone) continues to produce effects on the receptors until all receptors are fully activated or until the maximum effect is reached, resulting in relief of cravings, blocking of the euphoric effects associated with heroin and other opioids, and preventing withdrawal.

A partial agonist (buprenorphine) activates the mu receptors, but not to the same extent as a full agonist—the effects increase until a plateau is reached. Once a plateau is reached and maintained, those with opioid addiction will not experience withdrawal symptoms.

An opioid antagonist (Vivitrol) binds to the opioid receptors with greater affinity than agonists, but does not activate the receptors. They block the receptors, therefore preventing neurons from responding to opioids, effectively blocking the effects of opioids. The result is a reversal of the effects of opioids and is used in the management of opioid use disorder to aid in the prevention of relapse.

Research has indicated that both methadone and buprenorphine are equally effective, even though some patients—particularly those with a history of heavy use of illicit or illicitly acquired opioids—prefer methadone. The limitation to Vivitrol is that individuals must wait ten to fourteen days after last use of an opioid to prevent opioid withdrawal (Alderks, 2017), but it is still effective, which means this statement is fiction.

Fact or Fiction: “Methadone is the MAT drug of choice for pregnant opioid addicts.”

Stopping methadone during pregnancy or withdrawal from methadone in opioid-dependent pregnant women carries a high risk to the fetus, including spontaneous miscarriage and fetal death. Continuation of methadone during pregnancy is much safer for both the mother and fetus than a return to the use of illicit opioids (Kelly, Minty, Madden, Dooley, & Antone, 2011).

Methadone was considered the MAT drug of choice for opioid-dependent pregnant women to keep mothers and fetuses from going into withdrawal as well as diminishing the risk for the women going back to illicit opioids, which makes this statement fact. Though a study did find that buprenorphine alone—that is, not buprenorphine plus naloxone/Suboxone—resulted in neonates requiring less morphine to treat withdrawal symptoms and shorter lengths of stay in the hospital (Jones et al., 2012).

Conclusion

I think I can divide counselors reading this column into three groups: those who know and understand the content; those for whom the information may be new, but to which they are open; and those who have entrenched biases, which makes them less effective working with individuals with addictive disorders. I once heard a counselor say, “I don’t believe in that,” which to me sounded like “I don’t believe in insulin for diabetics.” When we use MAT, we are using an evidence-based practice. Let us not allow our biases and prejudices to function as an obstacle to our patients’ recovery.

References

“Alcohol recovery programs and support groups.” (2018). Retrieved from https://www.alcohol.org/aftercare/support-groups/

Alderks, C. E. (2017). Trends in the use of methadone, buprenorphine, and extended-release naltrexone at substance abuse treatment facilities: 2003–2015 (update). Retrieved from https://www.samhsa.gov/data/sites/default/files/report_3192/ShortReport-3192.pdf

Castaneda, R. (2016). Should people in recovery from alcohol or drugs use medical marijuana? Retrieved from https://health.usnews.com/wellness/articles/2016-11-16/should-people-in-recovery-from-alcohol-or-drugs-use-medical-marijuana

Institute for Research, Evaluation, and Training in Addictions (IRETA). (2013). Management of benzodiazepines in medication-assisted treatment: Final report on the development of clinical guidelines. Retrieved from https://ireta.org/wp-content/uploads/2014/12/BP_Guidelines_for_Benzodiazepines.pdf

Jones, H. E., Fischer, G., Heil, S. H., Kaltenbach, K., Martin, P. M., Coyle, M. G., . . . Arria, A. M. (2012). Maternal opioid treatment: Human experimental research (MOTHER) – Approach, issues, and lessons learned. Addiction, 107(1), 28–35.

Kelly, L., Minty, B., Madden, S., Dooley, J., & Antone, I. (2011). The occasional management of narcotic exposure in neonates. Canadian Journal of Rural Medicine, 16(3), 98–101.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2004). Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Treatment Improvement Protocol (TIP) Series 40. Retrieved from https://www.naabt.org/documents/TIP40.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA). (2018). Medications for opioid use disorder: For healthcare and addiction professionals, policymakers, patients, and families. Treatment Improvement Protocol (TIP) Series 63. Retrieved from https://store.samhsa.gov/system/files/sma18-5063fulldoc.pdf

Von Korff, M., Kolodny, A., Deyo, R. A., Chou, R. (2011). Long-term opioid therapy reconsidered. Annals of Internal Medicine, 155(5), 325–8.

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Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.