We’re Weighing the Pros & Cons of Different Medications

DanF1 seeks guidance about medication assisted treatment for their son. He’s tried some medications and they haven’t agreed with him. He has concerns about sleep and anxiety and they are wondering which approach may best suit his needs.

My 30 yr old son relapsed from using of fentanyl seven days ago (his 3rd relapse) we got him into detox the same day, he was on a methadone taper and was released four days later. Post detox he has tried Suboxone in the past and does not want to use that again. We have discussed Vivitrol, a shot that would last 30 days. Our understanding is that Vivitrol will block his brain receptors so that he won't get high but will not help him with sleep and anxiety/depression. We are meeting today with a doctor to review the pro & cons (knowing he must be off the methadone for at least 10 days). He starts outpatient therapy in 2 days and that will consist of four 3hr sessions for 2/3 weeks. My son wants to try Wellbutrin as he feels that will help with the sleep, anxiety, depression. Any thoughts on the approach and what else we can do to assist him?

Thank you

We were recently asked our position on medication assisted treatment (MAT) for opioid addiction. It’s a complex issue and we are actively involved in analyzing the research around this topic. Here is our response.

Your son’s relapses on fentanyl are very worrisome. I am glad he is willing to look at MAT. There are three drugs that help with opioid addiction: methadone, Suboxone, and Naltrexone (Vivitrol is the name of its monthly shot).

These drugs are not a walk in the park. The Suboxone would be more protective than Naltrexone, but he has to be willing to take it as directed. Unlike methadone, the patient is given Suboxone to take home, usually one to two weeks of dosing at a time. If I had to list the most protective to the least protective, I would put methadone first, then Suboxone, and then Naltrexone.

Naltrexone doesn’t prevent craving or withdrawal symptoms that can last months after stopping an opioid. Naltrexone simply blocks the feeling of being high when you ingest another opioid. For some, knowing that getting high will be pointless, makes this enough not to use. Does this sound about where your son is at the moment?

It is my opinion only, but with three relapses in the near past already, I would see if your son can be convinced to reconsider and step up to Suboxone or methadone.  There is a monthly implant of Suboxone now on the market. This takes away some of the games that get played with singular doses of Suboxone. Working in the jail, I’ve seen how some avoid Suboxone because they know they divert it. They know they will just get in trouble with it.

We recently lost a young man who had started on Suboxone after an overdose, but then quickly changed to Naltrexone. The young man waited for the 30-day period of Naltrexone to end, when the block is at its weakest, to relapse to opioids.

Perhaps your son has a good doctor who is willing to seriously address the lingering issues due to opioid withdrawal or his mental health condition (anxiety, sleep, depression). I say “or” because anxiety, sleep, and depression are so commonly remnants of withdrawal (which can last for months). It’s hard to know at this point if those conditions are underlying, or due to the withdrawals.

The monthly shot of Naltrexone can be part of the plan, but word on the street is that the shot loses its potency near to the 30 day mark. This unfortunately sounds mighty tempting to those who are not solid in their abstinence – whether or not this is true. It is possible to overcome the block of Naltrexone by taking more of an opioid, which can be super dangerous.

Your son is willing to work on his recovery outside of just MAT by attending an IOP. This is a very good sign. What else? I would like to see him firmly planted in a community of concern/self-help. This might be AA, Smart Recovery, or one of the many others coming online right now. During this time of social distancing amidst concerns about group gatherings, look at intherooms, as well as Smart Recovery, or other platforms that provide online meetings.

There are peer-led recovery centers opening up across Massachusetts and other states. Can you find one in your area? He can get a recovery coach there. Can the doctor do random urine “tox" screens (aka drug testing/ urine toxicology screens) during the month? This would catch an attempt at using opioids or any other drug. I say “catch” here not in a policing sense, but with his safety in mind. This measure isn’t about cornering your son, but in partnering with him to help build a protective wall around relapse. Knowing the random test may come any day can reduce the likelihood he will think of taking an opioid or other drug.  If there are drugs in a urine tox test, it is a moment for the doctor to call a meeting to discuss further measures or to reconsider Suboxone or methadone.

If I were in front of a doctor asking for Vivitrol I would ask if it is possible to get the shot every three weeks instead of four weeks. Your son also needs his other issues addressed. Wellbutrin may be the ticket: if it is not, move quickly to ask for additional medication options to help with these symptoms. They can drag on and pull people down even as they wage the heavy battle against addiction.

You pose a very good question. Thank you for writing in and sharing your situation. I hope these considerations are useful for you and your family. It is heartening to hear your son is participating in his relapse prevention plan. It is wonderful that you were able to step in and help him so actively at this critical time. Thank you for doing such a great job and for being there for your son. Let us know how things go, and what else we can do to help. Sending you and your family love and strength in this trying time.