ADDICTION is “hiding that harms” (Susie Wiet, MD). Any behavior that is compulsively repeated and harmful to self will eventually alter the biology of the reward system and become an addiction (e.g. the addiction pathway). This includes repeated use of addictive substances and stimulating behaviors (e.g. pornography, sex, gambling, self-mutilation, purging, anorexia, rage, etc.).  

 

Addiction IS:

- Avoidance of self and others (fear, guilt, and shame)

- Altered biology (receptors, neurochemistry, hormones, metabolism, and illness)

- Absence of a pause between stimulus and response (e.g. instant gratification)

- An adolescent disorder

 

Addiction is NOT:

- What anyone seeks to create 

- Wanted or desired 

- An issue about morality

 

Addiction WILL cause damage:

- Health (physical and mental)

- Relationships

- Careers

 

ADDICTION SEVERITY is based on criteria that determine mild, moderate, or severe addiction:

•   Taking larger amounts or for longer amounts of time.

•   Not able to cut down or stop using the substance.

•   A lot of time spent on getting, using, or recovering from use of the substance.

•   Cravings and urges to use the substance.

•   Not managing responsibilities.

•   Causing problems in relationships.

•   Giving up activities that were once enjoyable and important.

•   Putting yourself in danger.

•   Physical or psychological problems have been caused or made worse. 

•   Needing more for the effect.  

•   Withdrawal symptoms relieved by taking more of the substance.

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ALCOHOL

• ​Detox: several days to 2 weeks

  • Typically: in a hospital or free-standing overnight medical facility​

  • Selectively: outpatient or in-home

• Medications often prescribed for detox:

  • Benzodiazepines: lorazepam (Ativan), chlordiazepoxide (Librium), oxazepam (Serax)​

  • Anti-seizure medications: gabapentin (Neurontin), valproic acid (Depakote), carbamazepine (Tegretol), phenobarbital

• Dangers of withdrawal:

  • Seizures (low risk but about 3% turn into status epilepticus (can't stop seizing), can lead to death)​

  • Hallucinations and delusions

  • Increased metabolism: high blood pressure, heart rate, temperature

• Altered mental state: irritability, agitation, delirium tremens (most severe)

  • Nausea and vomiting: usually associated with very high blood alcohol level (BAL); can also be a precursor to alcohol poisoning​

• Supplements that may be helpful to support recovery and protect organs:

  • Brain and other nerve cells: B1 (thiamine), B9 (folate), B12 (cobalamine)​

  • Liver function: N-Acetyl-Cysteine, Milk thistle

  • Probiotics

  • Amino Acids: L-Tryptophan, L-Tyrosine, L-Theanine, L-Dopa, 5-HTP (These should be prescribed under the direction of a medical provider, since these can have interactions with certain medications)

• Medications often prescribed for recovery (Medication Assisted Treatment, or MAT)

  • Craving control: naltrexone (Revia - oral, Vivitrol - injectable), acamprosate (Campral)​

  • Deterrent: disulfiram (Antabuse)

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BUPRENORPHINE PRODUCTS (Suboxone, Sublocade, Subutex)

Opiate dependence can be treated by buprenorphine-based medications and can be mixed with naloxone, a powerful opiate blocker. Suboxone (with naloxone) and Subutex (without naloxone) were the first to market of the buprenorphine products, and these still have the most name recognition. Several brand name products are available with and without naloxone, and the generic forms are also available. This medication is typically taken daily and under the tongue; implantable forms are also available. 

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HOW IT WORKS

Buprenorphine is a partial agonist. This means that it partially stimulates the opiate receptor but not to its fullest potential. This effect essentially causes a block or plateau effect, which cannot be over-ridden by taking more of the medication or other opiates. Therefore, this medication can greatly reduce the risk of opiate relapse, overdoses, and related overdose-deaths. In combination with addiction-recovery focused therapy, the risks are reduced substantially more. 

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Buprenorphine + therapy + community support = dramatic reduction in relapse.

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Translation: 80 - 90% risk of relapse reduced to 20% - 30% at one year.

 

BENEFITS:

- Reduces the risk of relapse, overdoses, and death 

- Provides psychiatric stability by maintaining a steady neurochemical state - Reduces risk of getting too much pain medication that can cause secondary increased perception of pain. This is known as hyperalgesia.

 

RISKS:

- Withdrawal symptoms: Induction of buprenorphine can cause withdrawal symptoms, depending on when the last dose and type of opiate was used. Some of those symptoms may include insomnia, sweats, muscle aches, and irritability. Although unpleasant, these are rarely dangerous, and symptoms can be reduced with other medications and interventions. These symptoms typically continue through the first few days and rarely can last through a few weeks. 

- Medical complications from prolonged use: All opiates, including buprenorphine, can alter various functions or metabolism. Among the more common risks are constipation, risk of gallstones, hypoactive gallbladder, low testosterone or menstrual irregularities, and risk for osteoporosis.

- Dependence: Buprenorphine is a substitution therapy. This means that it stimulates that opiate receptor involved in addiction but does so in a much safer way than do other substances known to cause opiate dependence. If this medication is stopped abruptly, opiate withdrawal is predictable. This medication does require tapering-off to avoid withdrawal. 

- Interactions with medications: Any central-nervous-depressant medication or substance can further reduce respiration that is also associated with any form of an opiate. Some examples include benzodiazepines, alcohol, and some anti-seizure medications and muscle relaxants.

- Not taking the dose correctly: Buprenorphine cannot be swallowed and needs to be absorbed under the tongue (sublingually). If it is swallowed, there will not be absorption and can therefore cause withdrawal. If the medication is used intravenously ("shot up"), the combination product of buprenorphine/naloxone will cause an immediate opiate withdrawal state if that person had been using opiates recently. 

- Diversion of medications: Because it is an opiate medication, buprenorphine is a controlled substance. Therefore, selling prescriptions can result in legal action. We will not prescribe this medication to you if you have abused your prescription in this manner.   

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DETOX 

Some addictive substances require medications and monitoring for a safe detox. This usually means that a medical provider is overseeing the patient during detox.

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DUAL DIAGNOSIS is assessing for the combination of addiction problems, psychiatric problems, and/or physical health issues​

• ​Nearly 8 million adults battle both a mental health disorder and a substance use disorder. - SAMSHA

• The neurobiology of addiction is often interwoven with psychiatric disorders and can also cause physical health problems.

• Dual diagnosis is common but can be challenging to tease out and treat effectively.

 

GENETICS

We each are born with a genetic blueprint. Environmental influences (e.g. toxins, stress, trauma, nutrition, positivity) will either enhance or detract from how genes on the genetic blueprint are revealed. These influences will result in variations of good or poor health. This is similar to a blueprint for a home: not every part of a blueprint will necessarily be constructed and/or be the best design to withstand stress, but depending on how and with what materials a home is built, that home may vary in strength and durability.​​

• Epigenome is the constantly-changing environmental influences that shape the genetic blueprint

• The epigenetic effect is transferred to future generations

 

LEVELS of CARE

Addiction treatment has several levels of care. The sub-bullets indicate the types of services that are typically expected for each level of care. The ASAM level of care is indicated.

• Outpatient (ASAM 1.0): regularly scheduled office visits with a health care provider ​

  • ​Therapist

  • Medical Provider

• Intensive Outpatient Program (IOP, ASAM 2.1): 9 - 15 hours over multiple days per week 

  • ​​Group therapy

  • Individual therapy

  • Referral to a medical provider, as needed

• Day Treatment (Partial Hospitalization, ASAM 2.5): 6 - 8 hours per day, 5 days per week​

  • ​Group therapy

  • Individual therapy

  • Family therapy

  • Medical provider

• Residential Treatment Center (RTC, ASAM 3.0-3.5): residing at a facility, typically 30 - 90 days​

  • ​Group therapy

  • Individual therapy

  • Family therapy

  • Medical provider

  • Psychiatrist

• Hospitalization for detoxification (ASAM 4.0): typically 3 - 5 days for uncomplicated medical detoxification; 5 - 14 days for complicated detoxification​. Addictions that require medical detoxification include: alcohol, benzodiazepines and other sedatives, and opiates.

  • Medical team​

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OPIATES (heroin, pain killers, and kratom)​​

• Detox: 5 - 14 days

  • Typically: in a hospital or free-standing overnight medical facility​

  • Selectively: outpatient or in-home

• Medications often prescribed for detox are prescribed to address severe cravings often experienced with opiate withdrawal, along with other unpleasant symptoms such as sleep disturbance, anxiety, restlessness, bowel distress, etc.

  • Craving control: buprenorphine (Suboxone, Subutex, Zubsolv, Bunavail)​

  • Withdrawal symptoms: clonidine (Catapess), quetiapine (Seroquel), gabapentin (Neurontin), immodium, methocabarnol

• Dangers of withdrawal: an easy way to think about it is that "everything oozes"

  • Electrolyte imbalances from diarrhea and vomiting can lead to seizures or heart rhythm problems (rare)​

  • Altered mental state: irritability, agitation, intense cravings

• Supplements that may be helpful to support recovery and protect organs:

  • Brain and other nerve cells: B1 (thiamine), B9 (folate), B12 (cobalmine)​

  • Liver function: N-Acetyl-Cysteine, Milk thistle

  • Probiotics

• Medications often prescribed for recovery (MAT)

  • Craving control: buprenorphine (Suboxone, Subutex, Zubsolv, Bunavail), methadone, naltrexone (Revia: oral, Vivitrol: injectable)

  • Overdose reversal: Anyone can carry a Naloxone Rescue Kit and administer this medication, which can be life saving 

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OVERDOSE KITS: Overdose by opiates can be reversed with naloxone. Utah law now allows for any person to carry and administer naloxone as a rescue for an opiate overdose AND should call 911. These kits have been life-saving for many people. 

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SEDATIVES (benzodiazepines, hypnotics, GHB, barbiturates)​​

• Detox: 3 - 7 days, up to several months

  • Selectively: in a hospital or free0standing overnight medical facility to start reduction​

  • Typically: outpatient to continue tapering off

• Medications often prescribed for detox:

  • Benzodiazepines: typically a slow tapering off of current sedative, or switch to a long-acting benzodiazepine​ with a slow tapering off

  • Anti-seizure medications: gabapentin (Neurontin), valproic acid (Depakote), carbamazepine (Tegretol), phenobarbital

• Dangers of withdrawal (this includes a person who may be taking a sedative for a while, as prescribed, then abruptly stopping it):

  • Seizures (low risk, but about a 3% turn into status epilepticus (can't stop seizing); can lead to death)​

  • Sensory distortions, hallucinations, and delusions

  • Increased metabolism: high blood pressure, heart rate, palpitations, temperature

  • Altered mental state: irritability, agitation, panic, delirium tremens (most severe)

• Supplements that may be helpful to support recovery and decrease anxiety:

  • Vitamin B-complex (some people may need methylfolate)​

  • Vitamin D

  • Pharmaceutical-grade lavender essential oil

• Medications often prescribed for recovery:

  • Anxiety is very often an underlying problem; therefore, non-addictive medications that treat anxiety are often prescribed:​

    • Several antidepressants that are serotonin-based: SSRIs, some SNRIs, novel serotonin-receptor

    • Some anti-seizure medications: gabapentin (Neurontin), oxcarbazepine (Trileptal), other medications 

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SIGNS and SYMPTOMS: A person may cover up substance use for a long while before seeking help, or when someone else recognizes a pattern of addiction. Some clues may include: 

• Seeking to spend alone or in isolation (i.e. multiple excuses to miss out on activities with others)

• Not being able to limit use (e.g. can't stop after 1-2 drinks)

• ​Compulsive and deceitful behaviors (i.e. half-truths, lying, elaborate explanations)

• Sleep problems (insomnia or excessive amounts)

• Drop in productivity or activity (work, home, school, interests)

• Change in social group

• Intense mood swings, abrupt personality changes, or anxiety that is otherwise inexplicable

• Unexplained falls, bruises, weight loss, skin changes (sagging, gray, red, picking)

• Black outs or loss of time

• States of confusion or hallucinations

• Poor health (e.g. unusual infections, malnutrition)

• Unhealthy liver, heart, kidneys, or gut

 

STARTING MEDICATION 

​We start medication in this clinic under direct observation in order to use the optimum level of medication as well as to reduce any side effects that may result.  It is our experience that the best practice for initiating MAT is in a clinic setting, as opposed to home administration. Direct observation reduces the risk for relapse and/or adverse medication events.   

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TRAUMA: An emotionally painful event or series of experiences that is overwhelming, and causes a disconnect to one’s emotions and understanding of emotions. Trauma is often linked to addiction.​

• ​​Unresolved traumatic experiences will create toxic stress in the emotional part of the brain (limbic system). This toxicity will impact both physical health and the reward center of the brain.

• Toxic trauma is associated with poor health and addiction across its lifespan.

  • The effect of traumatic experiences can be resolved, which can dramatically improve health and long-term recovery for the individual and future generations.

• Addiction is often used to avoid painful emotions (numbing or pushing away emotions).

• Addiction-related behaviors can become a source of additional trauma.

• Sobriety can result in an increased recall or re-experiencing of traumatic memories; this may increase cravings to use an addictive substance to suppress intense emotions.

 

TREATMENT 

• ​Medication: An important tool for recovery, especially when combined with group therapy and community self-help meetings. Medication can be life-saving and is used for:

  • Detox

  • Maintenance of recovery

  • Relapse prevention

  • Medical and psychiatric conditions co-occuring with addiction 

• Therapy: Identifying core issues and developing healthy coping skills through discussion. There are specific techniques that are very helpful for sustained recovery, including trauma-resolution therapies. Types of therapy audiences include:

  • Individual​

  • Group

  • Couples

  • Family

• Community support and meetings: The cornerstone of recovery is making connections and building relationships that are based on integrity, responsibility, and accountability to yourself and others. Meetings are subdivided into AA (alcohol), CA (cocaine), CMA (crystal meth), GA (gambling), NA (narcotics), and SA (sex addiction).

  • 12-Step: AA was the original model for social recovery that has saved the lives of millions of people. Regular participation encourages making sober and supportive connection with others in recovery.​

    • First goal of recovery: "90 in 90" (90 meetings during the first 90 days of recovery) while starting to work through the 12-steps of recovery and establishing a 12-step peer sponsor​.

  • Dharma Recovery (formally known as Refuge Recovery): Supports recovery through regular meetings that are based on Buddhist principles, which includes meditation during each meeting.

  • Experiential:

    • Addict to Athlete: Groups are open to anyone touched by addiction (e.g. in recovery or affected by someone in recovery) who seek to establish and maintain sobriety through fitness (free)​.

    • Fit-2-Recover: recovery based on 4 principles: fitness, nutrition, community service, and creative arts (membership fee)

    • Full Circle Yoga: offers yoga, community meetings, and some therapy services

  • Professionals Helping Professionals (PHP): Several professional groups (e.g. physicians, attorneys, therapists, etc.) support professional peers through discipline-specific challenges of recovery. The meeting schedules are not publicized.

  • USARA (Utah Support Advocates for Recovery Awareness): A unique resource for all people active in the recovery process. They recognize that recovery takes on as many paths as there are individuals.​

• Health: Balancing health is very important for sustained recovery. Health can be influenced in many different ways and include:

  • Psychiatric: Assess, treat, and stabilize mental and emotional problems that have resulted from or contributed to addiction​.

  • Internal medicine: Assess and treat physical health problems related to addiction.

  • Nutrition: Assess and provide instruction to balance metabolism, optimize health, and recovery through food.

  • Yoga and meditation: Develop awareness of self, connection to others, and deeper meaning of life.

  • Sleep: Addiction can cause problems with getting restful sleep. When sleep is a problem, it is more difficult to maintain health.​

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VIVITROL (INJECTABLE NALTREXONE)

Vivitrol is an excellent choice for opiate and alcohol dependence. This is a monthly injection that is typically well-tolerated. It functions by blocking a particular opiate receptor in the brain, which can greatly reduce risks for relapse and death by overdose.

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Prior to starting injectable naltrexone (Vivitrol), we will require an oral test dose and require that all patients abstain from any opiate medications for a minimum of 7 days in order to avoid precipitated withdrawal. If this is not possible, we can often implement other strategies to assist with making that transition as smooth as possible.

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Benefits of naltrexone:

• Blocks opiates from occupying the receptors.

• Reduces cravings for opiates, alcohol, and reduces relapse from alcohol and opiates, as well as many other forms of addiction. 

• Some may also experience overall improvements in mood and reduction of anxiety.

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Risks:

• Opiate withdrawal: The first dose can precipitate a withdrawal state. This can be extremely uncomfortable and stressful, although it is not typically considered a medical emergency.

• Allergic reactions: These are rare for naltrexone but theoretically can happen. We minimize this risk by starting an oral dose first: We can stop an oral dose, but we cannot take out an injection. One of the most concerning but very rare allergic reactions associated with naltrexone is an allergy-induced pneumonia.

• Liver irritation: Rarely, liver enzymes can elevate, making it harder for the liver to function. For this reason, periodically checking liver enzymes is important.

• Emergency pain medication: Naltrexone blocks the effects of opiates for pain control. Therefore, it is important that you carry in your wallet or wear identification that you are prescribed naltrexone. A skilled anesthesiologist can still safely treat pain for emergencies and during and after emergency surgery.

 

For patients with any addiction, including Alcohol Use Disorder and Opiate Use Disorder, blocking the opiate receptors in the brain has been demonstrated to greatly reduce relapse and death.