The opiate deficit
One of the ways to look at opiate dependency is to view the problem as an opiate deficiency. People aren’t born with this condition. The deficit develops as a result of using much larger amounts of drugs that act at opioid receptors than would naturally occur. Our brain normally has only small quantities of endorphins (our bodies naturally occurring opioids) present. The exposure to large quantities of a similar compound changes things.
In some ways this is similar to developing one type of diabetes. Type 2 diabetes may occur after long-term exposure to larger quantities of simple sugars and other carbohydrates than the body needs to fuel a particular level of activity. This results in several changes including a decreased sensitivity to insulin. This exposure changes things – these people now need more insulin. They have an insulin deficit.
The bottom line is opioid dependent people have developed a need for a certain amount of opiates just to function; people without this problem do not. In fact opioids are the only substance of abuse where to dependent person needs a certain amount of the substance to be normal. In fact the Ministry of Transport understands this – people on methadone or suboxone are allowed to drive transport trucks. Because they are normal.
We could imagine a small pit on the surface of their brain. If this is filled with opiates they feel normal. Too much and they feel high, none or not enough and they don’t function well. Only opioids will fill this deficit -other drugs and combinations have been tried but do not work.
Methadone and Suboxone work because they are opioids – they fill the deficit.
Dependency vs. Opioid Use Disorder (OUD)
Dependency is defined by tolerance to a substance and a recognized withdrawal syndrome when the substance is discontinued. Dependency is inconvenient at times but it is possible to lead a normal and fulfilling life dependent on a medication that is an effective treatment – again think diabetes. Consider the following:
A 65 year old widow lives next door to me. She has rheumatoid arthritis but between her immune modulating medications and taking long acting oxycodone twice per day she is able to garden, take care of her house, her grand kids a couple of days per week and bake pies with the church ladies. She is considered a great neighbor. She never takes more of her medication than she should, she doesn’t use it to get high or for emotional support if she has had a bad day and has not altered the route of administration of her opiate – she always takes a whole pill orally as directed. However, if her family doctor went out of town and her prescription was not refilled she would go into the same withdrawal that someone with OUD would. She is opiate dependent but has a productive and fulfilling life.
OUD is different. People with addictions (use disorders) have a dependency but also develop maladaptive behaviors – mal means bad and adaptation means they didn’t have the behaviors before they developed problems with the substance. The behaviors are mostly based on three things – finding and acquiring the drugs and also hiding from people that they need the drugs and not changing their behaviors even though they know they are causing themselves and others harm.
At first they withdraw from things they used to like doing then they withdraw from friends and then family. They start spending time with new “friends”. They divert money from where it should be going and then they start doing things they would have never imagined like lying, cheating or stealing. Some engage in prostitution or get drugs from their drug-dealing “friend” as part of the arrangement – trading drugs for sex. Some start selling drugs to keep up with the cost of their habit. They may even try to recruit new people to drug use. Eventually they become alienated from their family and get in trouble with their boss or agencies like the police, Children’s Aid, Canadian Revenue Agency, Ontario Works etc. At some point they look in the mirror and ask “who am I”. Most try quitting at least a few times on their own but find they can’t function without opioids. This is when they first think about coming to BMC.
What we do at BMC is help the motivated person with OUD by providing them the correct dose of the medication their brain needs to function. Once their brain is taken care of they usually take the opportunity and start changing their life – a process known as recovery.
In short, motivated people with OUD gradually transition to being just opiate dependent. They lose the maladaptive behaviors, go back to being their old selves and re-enter society. Being opiate dependent does not prevent one from having a happy productive and fulfilling life. Having OUD most definitely does.
Is methadone and buprenorphine maintenance just switching one drug for another?
Many opponents of methadone and buprenorphine therapy suggest that our patients are just switching one drug for another. This is wrong – imagine an alcoholic telling you he got off the beer by drinking wine. Obviously, he is still drinking alcohol.
Anything that works at the opioid receptors can be considered an opioid. Our patients are still taking opioids because opioids are the only class of compounds that will fix the opioid deficit. Essentially they are still taking the same “drug”, they have not switched one for another.
The difference is, of course, that now the opioids are in the form of a prescribed medication which is closely monitored by a team of physicians, nurses, case mangers and pharmacists. The patients no longer have to pursue the illicitly acquired drug with all the associated risks and expenses of doing so. Finally, they are again free to make choices. Most make the right ones.
The CRISM (Canada Research Initiative in Substance Misuse) Guidelines
These recommendations for the treatment of OUD were published in March 2018 and are the consensus of many addiction experts from across Canada and based on available research data. This document is available on-line https://crism.ca/projects/opioid-guideline/
Here are 4 important points with moderate to high quality levels of evidence to back them:
Approaches to Avoid:
- Abstinence based care as it is ineffective and leads to a higher mortality rates. For example, even after a week without opioids people lose some of their tolerance and so have a much higher risk of overdosing when they are released and use opioids. This has been seen after withdrawal management (detox), residential treatment (Rehab) and release from incarceration (unless on opioid replacement therapy in prison).
First and second line treatment options:
- Buprenorphine is the first line therapy;
- If buprenorphine is not tolerated or effective switch to methadone;
- Consider switching to buprenorphine for stable methadone patients who desire treatment simplification.