Our Alliesinrecovery.net member seeks guidance about medication for Opioid Use Disorder for her son. He’s tried Suboxone and Methadone and is looking for an alternative. He has concerns about sleep and anxiety, and our member is wondering which medications may best suit his needs. Allies Director Dominique Simon-Levine gives a detailed answer, as well as some great CRAFT pointers for supporting his recovery.
“My 30-year-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 3-hr 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.”
[This question originally appeared on the Allies in Recovery Member Discussion Blog, where experts respond to members’ real-life questions and concerns.]
Your son’s recurrences* on Fentanyl are very worrisome. Fentanyl is extremely potent and widespread in much of the street heroin traffic. I am glad your son is willing to look at Medication for Opioid Use Disorder (MOUD). There are three drugs available that help with opioid addiction: Methadone, Suboxone/Subutex/Sublocade (Buprenorphine), and Naltrexone (Vivitrol is the name of its monthly shot).
Medication reduces potential injuries associated with opioid addiction. It does so in 3 ways:
1) Methadone or Buprenorphine fill the receptor sites on the neurons the illicit opioids previously filled, and so reduce much of the craving for the opioid and either one stops withdrawal. Naltrexone – Vivitrol is the name of the monthly shot – only blocks the feelings of being high. It does not help with cravings or withdrawal.
2) There are many well-designed studies that show that Methadone and Buprenorphine reduce opioid overdose deaths by at least sixfold.
3) There is also good evidence that Methadone and Buprenorphine cut the number of recurrences (relapses) to opioids in half, when the dosage is right. For Buprenorphine, the study authors note that Buprenorphine must be given at doses 16mg or greater for recurrence/relapse rates to drop.
A Comprehensive View of Treatment Options for Opioid Addiction:
Below is recent research on Medication Assisted Treatment for Opioid Use Disorder (MOUD), including comparison studies and benefits vs. risks:
These drugs are not a walk in the park. The Suboxone would be more protective than Naltrexone, but your son must be willing to take it as directed. Naltrexone doesn’t prevent craving or withdrawal symptoms that can last months after stopping an opioid. Naltrexone simply blocks the feelings of being high when you ingest another opioid. When Naltrexone works, knowing that getting high will be pointless stops people from using. This is enough to not use in the moment. Does this sound about where your son is in terms of his desire to stop using? Your son is not yet clear of opioids. He must be at least ten (10) days away from his last dose of methadone to move to naltrexone. Ask him if he can see tolerating the opioid withdrawals and not end up using out of the discomfort of the withdrawal.
If it is Naltrexone/Vivitrol be aware that the word on the street is that the monthly shot loses its potency near the 30-day mark. This unfortunately sounds mighty tempting to those who are not solid in their abstinence. It is also possible to overcome the block of Naltrexone by taking more and more of the opioid, which can alone be super dangerous, but even more so at the end of 30 days abstinence and a much-lowered tolerance.
Stepping up to Suboxone or Methadone: Some considerations
It is my opinion only, but with three recurrences in the near past already on methadone, I would see if your son can be convinced to reconsider and step up to Suboxone or Methadone. There is a monthly implant of buprenorphine/suboxone now on the market. This can discourage some of the games that get played with singular doses of Suboxone, which can be sold on the street for $5 as an alternative to street drugs, for someone experiencing cravings or seeking to avoid withdrawal. Working in a jail setting, I’ve seen how some avoid accepting Suboxone while incarcerated because they know they’ll end up diverting away from it when they’re back out on the streets.
We recently lost a young man who had started on Suboxone after an overdose, but then quickly changed to Vivitrol. His 30-day period of abstinence—creating a very low tolerance for opioids—matched with his using opioids near the end of the 30-days when the opioid block from the Vivitrol is at its weakest proved to be fatal.
Using random “tox” screens
In terms of your son and Naltrexone (Vivitrol): 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 the possibility of recurrence. 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.
Addressing Sleep issues, Depression, and his Environment
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 advocate for other medication options to help with his symptoms. The symptoms can drag on and pull people down even as they wage the heavy battle against addiction. Whether the mental discomfort is a result of the withdrawals will take time to determine. But your son needs everything he can have to be comfortable. This would include a safe space, time off from work, and access to recovery supports with transportation. Those around him must realize he will be low, flat, probably not sleeping… Your son is healing from a serious physical condition.
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, depression, sleep, etc.,). 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 which of those conditions are underlying, and which are due to the withdrawals. A psychiatric evaluation and medications can support his recovery by reducing anxiety and lowering depression.
Keep Using CRAFT to help you both get through this
Our eLearning Module 8 on the Allies site provides a brief tutorial on protective measures against recurrence through a daily focus on recovery. In it, we remind you that:
- No one stays away from mis-using substances for long by sitting on the couch.
- Your loved one will need to keep a daily focus on recovery. This means meetings, groups, counseling, or readings. EVERY DAY.
- Your loved one needs activities that compete with drug use, such as exercising, volunteering, spending time with non-using friends, spending time with children; or doing meaningful work, taking courses, or pursuing a passion.
- Use the principles we show you in our eLearning Modules to reward non-use, to help influence your loved one to stay in treatment, and to pursue protective measures that will keep them from recurrences.
Some of the CRAFT-based activities we suggest can include things like:
- praising your loved one after going to a counselor
- getting an ice cream together after an AA meeting
- give him a hug and thank him for sticking with the Naltrexone injections
- pick up the cost of a gym membership
- go walking or jogging together
- organize an outing to the park with the family
Remember, you can’t keep your loved one from using, but you can create an environment that is conducive to not using.
You posed a very important question. Thank you for writing in and sharing your situation. I hope the considerations we offered above are useful for you and your family. It is heartening to hear your son is participating in his recurrence prevention plan. He is blessed to have you by his side, stepping up and helping him so actively during 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 during this trying time.
*”Recurrence” is the preferred word now in the recovery community. “Relapse” is considered a stigmatizing word. For example, most people use the term “recurrence” for other chronic diseases that, just like with substance use disorder (SUD), have varying degrees of success or adherence after treatment. Also see our blog post https://alliesinrecovery.net/the-power-of-language-and-stigma-in-the-world-of-addiction/