Introduction

Addiction is a worldwide problem that affects many different people, their families, and communities. In 2014, about 435,000 Americans ages 12 or older reported currently using heroin, and 4.3 million reported nonmedical use of prescription opioids. Addiction is a chronic disease, like diabetes or heart disease, meaning there is no cure. But addiction can be managed, and people with addiction can, and do, recover.

Treatment using safe and helpful methods provided by trained clinicians can lead to a healthy, positive way of life. This healthy way of life is referred to as recovery. Treatment with a medication along with counseling and other support is often the most effective choice for opioid addiction and part of recovery.

This document provides facts about treatment from The American Society of Addiction Medicine (ASAM) – the leading medical society for addiction treatment. Learn more about ASAM  at www.ASAM.org.

Definition of Addiction*

Addiction is a chronic brain disease in which a person regularly finds and uses drugs, or regularly does something (such as gambling) despite the negative things that can happen. It is a brain disease because addiction can change how the brain works. Besides harming a person’s health, it can change how someone thinks and feels. This may last a long time, lead to other harmful actions, and cause difficult relationships with family and friends. Without treatment and recovery, addiction may keep getting worse.

*Modified from ASAM Definition of Addiction

www.asam.org/for-the-public/definition-of-addiction

Assessment

Seeking help is the first important step to recovery. The next step in the process is to meet with a qualified clinician. A clinician is a health professional, such as a physician, psychiatrist, psychologist, or nurse. The clinician will review or assess how someone is doing - this first meeting is called an assessment. The goal of the assessment is to gain a thorough understanding of the patient. This will help the clinician and patient develop a treatment plan that best matches the patient’s needs.

Getting Started

  • The clinician will ask questions to understand nearly every part of a patient’s life. The more that is known, the better treatment can be planned with the patient.
    • Common assessment questions include:
      • How long has someone been using drugs?
      • What other medications are being taken?
      • Are there special social or financial circumstances, or needs?
      • Is there a family history of addiction?
      • Are there other mental or chronic health problems?
  • The next step is a complete physical examination to check the patient’s overall health. This includes finding other common conditions (physical or mental) related to addiction which may change how a patient is treated.
  • The physical examination will include tests to find both health problems and drugs in someone’s body. The most common drug test uses a patient’s urine and is called urine analysis.

Treatment Overview

After the assessment, the clinician will discuss all recommended treatment options with the patient. Every patient situation is different, so choosing the best options is a shared decision between the patient and the clinician.

There are three main choices for medication to treat opioid addiction: methadone, buprenorphine and naltrexone. These medications are used along with counseling and other support.

Treatment can occur in several different places or settings depending on the medication used, the patient’s situation and other factors. Four broad treatment settings should be considered: ASAM Level 1 (outpatient), ASAM Level 2 (intensive outpatient or partial hospitalization), and ASAM Levels 3 and 4 (residential addiction treatment or hospital settings). It’s important to discuss the many different treatment settings with the clinician to determine which is most appropriate.

Treatment Plan

  • After discussing the assessment and treatment choices with the clinician, including the ASAM Level of Care, it’s time to finish the treatment plan.
  • It is common for both the patient and clinician to sign an agreement about what to expect during treatment. This can include: treatment goals, which medications are used, treatment schedule, and counseling plan.
  • The treatment plan will also include:
    • Regular visits to the treatment center/clinician
    • Medications: usually methadone,
      buprenorphine or naltrexone
    • Patient commitment to cooperate with treatment
    • Risks of relapse and other safety concerns.

Patient Participation

  • At the same time, a patient should expect to be treated with respect and dignity and have concerns listened to when starting or changing the treatment plan.
  • To avoid health problems, patients must share with clinicians any other medications they are taking or if they drink alcohol regularly. This is very important – certain medications and regular alcohol use can cause major problems with certain treatment medications.
  • Common patient responsibilities include:
    • Keeping all appointments
    • Agreeing to drug testing on a regular basis
    • Taking medications as prescribed
    • Only using drugs that are prescribed
    • Allowing and encouraging involvement of family and friends
    • Avoiding persons, places and situations that may cause a person to use a substance again after a period of not using—also known as relapse.

Counseling

  • Counseling is an important part of treatment and is usually required with all medications.
  • Counseling should be done with a qualified clinician or health professional – this person will play an important role with the care team. Counseling may be done in the same place the medication is given, or by another clinician outside the treatment setting.
  • Counseling helps patients address personal, social or
    other problems that may contribute to their addiction. Examples can be:
    • Improving feelings of self-worth
    • Difficult situations at work or home
    • Spending time with people who use drugs or alcohol
  • In addition to counseling, patients are also encouraged to join support groups that include other patients who are also in recovery.
  • Counseling is not limited to the patient - there are also many support groups for family and friends of those dealing with addiction. Remember, addiction affects friends and family as well.

Support from Family and Friends

  • Families and friends play a key role, and should try to learn as much as possible about addiction to improve the chances of a long-lasting recovery.
  • Places, persons and events associated with addiction may contribute to a relapse. It is very important that a patient avoids persons, places and other reminders of his/her drug use or learn how to respond to those reminders in ways that do not involve alcohol or drug use. This requires the continued support and encouragement of friends and family who are outside of that environment.

Withdrawal

  • Opioid withdrawal refers to the wide range of symptoms that occur after stopping the use of opioid drugs. Withdrawal can last up to 10 days, but is most often between 3-5 days.
  • Although it can cause very troubling symptoms (such as vomiting, cramps, and sweating), withdrawal is rarely life-threatening.
  • Using medications to control withdrawal (also called withdrawal management) is almost always recommended over trying to quit “cold turkey.” When patients do try to quit “cold turkey,” it can lead to stronger cravings and continued use.
  • Withdrawal management on its own or with counseling is not treating opioid addiction and may increase the risk of relapse. When treating someone for opioid addiction, maintenance medication in combination with counseling and other support is recommended. Maintenance medication is defined as medication (see page 7) on a consistent schedule for persons with addiction.

Medications To Treat Opioid Addiction

MedicationBrand Names
BuprenorphineProbuphine*, generics
Buprenorphine and naloxoneSuboxone®, Zubsolv®, Bunavail®, generics
Methadonegenerics
NaltrexoneVivitrol® (injection), generics

Recently approved by the FDA for maintenance treatment of opioid dependence in certain patients.

Medications

Most treatment plans will include medication. The type of medication chosen depends on a number of factors, including the patient’s different situations and the treatment setting.

  • The most common medications used in the treatment of opioid addiction are methadone, buprenorphine and naltrexone.
  • Counseling is recommended with the use of each of these medications.
  • Each medication works in a different way and has its own risks and benefits. It also has a special way to be started—once started, it can be safely taken for years. The clinician and the patient should review together the risks and benefits of each medication.
  • When used properly, these medications will NOT create a new addiction – rather they help patients manage addiction so they can recover.
  • Some people have special situations, such as pregnancy, mental health issues, pain, or they are in the criminal justice system. They should work with their clinician to find the right medication for their situation.
  • Adolescents and their caregivers should also discuss medication options with their clinicians.

If the first medication selected does not work well, the patient can discuss with the clinician to find the right medication for his/her needs.

Methadone

  • Methadone acts as an opioid in the brain to reduce the desire to use the problem drug. The patient taking methadone feels normal (not high), and withdrawal does not occur. Methadone can also reduce cravings.
  • Methadone can be safely started at the beginning of withdrawal.
  • Methadone comes in a pill form, as a liquid, and a wafer. It is taken once per day, but over time the dosing may change.
  • People who are in stable recovery may be provided a supply of medication to take at home.

Buprenorphine

  • Buprenorphine also acts as an opioid in the brain to reduce the desire to use the problem drug, which helps the patient avoid withdrawal symptoms. It reduces powerful desires for opioids or cravings.
  • Buprenorphine comes as tablets and as film. Many versions of this medication are combined with naloxone to prevent possible misuse – when misused (injected, snorted, or other) it can bring on unwanted withdrawal symptoms.
  • Patients should wait until they are experiencing mild to moderate opioid withdrawal before taking the first dose of buprenorphine.
  • Insurance coverage and price may help determine which form should be chosen. The clinician will make sure the patient has a dosage and form that meets his/her medical needs.
  • This medication is taken once per day. The dosage taken per day may be adjusted over time.
  • Not all clinicians can prescribe buprenorphine, so it is important to find an approved clinician who is able to
    prescribe this medication.

Naltrexone

  • Naltrexone works by blocking opioids from acting on the brain - this takes away the ability to get high from using opioids. This makes naltrexone a good option for preventing relapse, but may not stop all drug cravings.
  • A person cannot have any opioids in his/her body when starting naltrexone. If a person does, withdrawal will be very strong. Before a clinician starts a patient on naltrexone, the patient must go through withdrawal under a clinician’s supervision. This period can last anywhere between 7-10 days.
  • Naltrexone comes in a pill form that is taken regularly. It is also available in an extended release form that is injected in the buttocks. The injection is administered by the clinician in his/her office once a month.

Medication Use Summary

  • Every patient is different, and the right medication is found when the person feels normal, has little to no side effects, does not feel withdrawal, and has cravings under control.
  • When used correctly, and when the treatment plan is being followed, these medications can be taken safely for years.
  • Any plans to stop taking a medication, change dosage, or switch medications should always be discussed with the clinician – this should be a shared decision, with all benefits and risks discussed and understood between both parties.
  • Patients will continue to see the clinician and participate in counseling and support groups based on the agreed upon treatment plan.
  • Relapse may occur as part of this chronic disease. If a patient relapses while using medication, the clinician will revise the treatment plan and treatment goals as needed.

Warnings

  • Medications should be kept at home, and must be locked in a safe place.
  • Women should let their clinician know if they are pregnant or breast feeding.
  • Patients on these medications should not use other opioid medications or illegal drugs. They should not drink alcohol or take sedatives, tranquilizers, or other drugs that slow breathing. This can cause deadly side effects.

Overdose

AN OPIOID OVERDOSE NEEDS IMMEDIATE MEDICAL ATTENTION

Dos and Don’ts in Responding to Opioid Overdose

  • DO Call for Help (Dial 911)
  • DO support the person’s breathing by administering oxygen or performing rescue breathing.
  • DO administer naloxone (a drug that reverses the effect of opioids) as an injection or a nasal spray.
  • ALL FRIENDS/FAMILY SHOULD HAVE NALOXONE AND KNOW HOW TO USE IT.
  • DO put the person on their side, if he or she is breathing independently.
  • DO stay with the person and keep him/her warm.
  • DON’T slap or try to forcefully stimulate the person — it will only cause further injury. If shouting, rubbing knuckles on the sternum (center of the chest or rib cage), or light pinching will not awaken the person, he or she may be unconscious.
  • DON’T put the person into a cold bath or shower. This increases the risk of falling, drowning or going into shock.
  • DON’T inject the person with any substance (salt water, milk, “speed,” heroin, etc.). The only safe and appropriate treatment is naloxone.
  • DON’T try to make the person vomit drugs that he or she may have swallowed. Choking or inhaling vomit into the lungs can cause death.

Naloxone

Naloxone is used to treat an opioid overdose if someone has taken too much. It can be injected or sprayed in the nose. Naloxone only works for opioids. It may need to be given more than once for an opioid overdose since its effects my wear off before the opioid does.

To ensure patient safety, the clinician should also provide a prescription for naloxone for the patient and family members. Having naloxone can help to save a person who may relapse or take so much opioid that she\he stops breathing.

Questions to Ask Your Clinician

  • What are the symptoms of opioid addiction?
  • What type of treatments are available?
  • What should I do if I think I have an opioid addiction?
  • How long do I need treatment?
  • How long will I need to be on medication?
  • Where can I find more information on treatment and recovery?
  • Are opioid treatment medications addictive?
  • Are there differences in cost for treatment medications?
  • Does insurance cover the cost of treatment medications?
  • Where will I be treated?

The American Society of Addiction Medicine represents leading addiction care providers dedicated to ensuring individuals suffering from addiction can access high quality care and enter into long term recovery.

For additional treatment and support resources visit: www.asam.org/guidelines