Don’t Give Up Too Soon On Medication-Assisted Treatment

ColoradoGal‘s son is struggling to quit opioids, but the path is hard. He’s had many rounds of detox, and is now trying to self-medicate. An initial attempt at Suboxone treatment made him feel emotionless and flat. But did it have to be that way? Allies’ CEO Dominique Simon-Levine reviews the challenges and great promise of Medication-Assisted Treatment (MAT). MAT therapies often come with a period of adjustment for our Loved One’s.

Our Loved One just got out of his 10th detox/rehab in July…this time for fentanyl. He finally agreed to try Suboxone treatment but says that it tamped him down so much that he could hardly speak or experience any emotions. He says he “didn’t feel like himself.” He seems to be at a loss for what to do. He has backed off the Suboxone and is now self-medicating (not with fentanyl). What he has said is that “he’s so tired of failing.” He is living with us, is working, but not dealing with his legal issues. I am trying to stay backed off and let him come around to the decision to go back to rehab to try again. My question is: are there medications that can help with the depression or the feeling of unhappiness that comes with the MAT? Is one opioid treatment better than another? Benzos aren’t an opinion for him. What about Mirtazapine? Any help or advice would be greatly appreciated! Thank you for the great resource that you provide!!!

Hello and thank you for your question. Your son is struggling with opioid use disorder, and after many admissions to detox and inpatient rehabilitation centers, has only recently been willing to try Suboxone, a drug that is prescribed in a doctor’s office and that prevents withdrawal and reduces cravings for opioids.

A lot goes into a successful course of MAT

Suboxone includes an opioid blocker (naloxone) as well as an active opioid (buprenorphine). You should also know about Methadone, which is delivered in special clinical settings, and contains only an active opioid.

Your son didn’t like the feeling the Suboxone gave him. He stopped taking it and is now trying to manage his addiction with another opioid. I wonder how long he gave the Suboxone to work? I have evaluated MAT programs and have myself been on several of these opioid drug treatments. Prescribing either Suboxone or Methadone can be a process. The doctor often adjusts the dose up or down until the person is comfortable. This can take repeated visits, but that feeling of being emotionally flat should have been addressed.

After dosage adjustments, your son should feel normal, like he has not taken a drug. The goal of MAT is to feel normal, with far fewer cravings and no withdrawal. Could it be that this initial period wasn’t handled right, either by the clinic or by your son?

A process with promise

Medication-Assisted Treatment is critically important. It reduces overdoses by 50%, and your son is at high risk of overdose. Suboxone enables your son to cross over to a legally prescribed drug and almost instantly eliminate all worry of the withdrawals he would face should he try to detox on his own without the assistance of medication.

Allies’ spelled out our position regarding MAT several years back. Whether we like the idea of MAT or not, we continue to be in the state of a public health emergency, and these drugs protect individuals from life-threatening overdoses.

Street drugs are not a safe alternative

In a perverse way, your son might even be in greater danger now. Fentanyl is exceptionally dangerous, and tolerance for it only increases with continued use. When your son was taking it intentionally, he could at least attempt to regulate how much he used (again, with absolutely no guarantee of success). But when it comes to street drugs, fentanyl is showing up in everything. It’s cheap, powerful, and hard to detect. In the Northeast, where Allies is based, fentanyl has been found in much of what is confiscated by police and analyzed by overdose prevention specialists and research programs. Word among recovery specialists in our communities is that “there is no heroin on the streets – it’s all fentanyl.”

Bottom line: If your son tries to manage his addiction with something other than a legally-prescribed and obtained drug, that something might well be laced with fentanyl. He could easily end up taking a life-threatening dose.

Your son is also struggling with depression. Buprenorphine has actually been found to help with depression. One intriguing very small study that found naloxone (brand name Narcan or Evzio) the blocker in Suboxone, worsens depression in high doses. This finding is very early, and only applies to very high doses (high enough to reverse overdose). Remember, Suboxone is a combination of buprenorphine and naloxone. When a person injects Suboxone, the naloxone simply pushes the person into withdrawal. So it is not beyond the realm of possibility that your son is feeling effects of the naloxone in the Suboxone.

Perhaps the clinic would agree, and consider putting your son on a slightly different MAT such a Subutex, which is buprenorphine without the naloxone. This is the very same medication prescribed to pregnant women in recovery from opioids.

Nonetheless, that flat feeling, lacking all emotion, sounds more to me like a response to the initial dosing of MAT. Because your son came to the MAT provider with an addiction to fentanyl – a potent synthetic opioid – my hunch is that the provider started him on a rather high dose of Suboxone. It could be that your son had trouble with his initial dosing period and stopped short of reaching his therapeutic dosage (i.e. having his dosage adjusted properly) or perhaps the provider failed to identify to his needs.

The study of drug withdrawal is in its infancy. Here’s a TED Talk from 2015 that describes one person’s journey as he attempted to withdraw from his prescribed Oxycontin. Withdrawal experiences vary, but your son, in trying to quit all opioids, can likely expect not to sleep well, to struggle with low moods and to have low energy for an extended period—perhaps a month or more.

Don’t put off responding to his depression

As for the depression, opioid addiction is a rough ride. We may be talking chickens and eggs here: whether your son was drawn to opioids because of low feelings or the addiction created feelings of depression is hard to differentiate, and may be moot at this point. Ultimately, your son needs to be evaluated and perhaps even treated for depression.

Depressed feelings certainly happen in withdrawal from opioids, and not just during the acute stage of withdrawal. Symptoms can and often do last well beyond the period a drug has technically left the biological system, perhaps for months in some cases.

Your son lives at home, is employed, and is actively attempting to manage his opioid withdrawal with other opioids. The low feelings and depression are real and to be expected; it would be best for him to be promptly assessed and treated by a professional (I’d suggest a psychiatrist). It is well-known that depression, low mood and lack of energy so often lead to relapse. Would your son agree to see a psychiatrist or, short of that, a prescribing nurse practitioner?

He’s attempting something unbelievably hard

As someone who has been where your son is, I am finding it difficult not to be emotional as I write this. I am impressed by his efforts to get his life back on track. He lives with you, has a safe home, a job, and is trying to rid himself of an addiction to opioids. He’s trying. Honestly, confronting one’s addiction is just that hard – and it takes time to find the right pathway to recovery.

Even though he’s had trouble with it initially, do consider Suboxone/Subutex again, or perhaps Methadone as an alternative. One of these could make an immense difference. Clinics that provide Suboxone/Subutex and Methadone employ specialists who know how to titrate patients off their drugs when the patient is ready and willing to try. Once he reaches a therapeutic dose, his icky, uncomfortable feelings will quickly fade, and he’ll soon be able to get away from street drugs and all the hazards they employ.

By continuing to substitute street drugs for straight fentanyl, you son may also be subjecting himself to a protracted period of low-level withdrawals. Those other drugs may relieve his suffering temporarily, but they can lead to more discomfort if he misses a dose or occasionally takes more to get high. We know how often withdrawal symptoms lead to relapse. And again, most critically, a fentanyl-laced street drug is an immediate threat to his life.

With a well-coordinated titration schedule, your son can become drug-free in a reasonable amount of time. He can also be more comfortable than he is now by getting on the right dose of MAT, and separately, having his depression treated by a professional.

Module 8 describes the components of a CRAFT-style intervention – very different from the old-school notion of intervention! Key Observation Exercise #21 provides the cues for scripting out what you would say. I suggest you follow the module, complete the corresponding exercise, and attempt a small informal conversation urging your son to reconsider MAT. Within this conversation, you can present him with a few options for MAT providers, as well as treatment providers for depression.

It sounds like you have been through so much with your son. He is motivated to stop using drugs: that’s vitally important and something to recognize and affirm. I salute you all.

Your son is so close. Your continued search for understanding and support, for both him and yourself, is at the heart of the Allies’ mission. Families on this site continue to amaze me. Thank you for writing in.