Updated: Apr 16, 2019
Originally posted on rehabcenter.net September 24, 2018
Managing Opioid Use Disorders (OUD) with medication under the care of a physician can be the difference between life and death. When this approach is coupled with counseling, vocational and other supports, the effects can be life changing for the user as well as those who love them.
Medication Assisted Treatment (MAT) with Buprenorphine and Naloxone (or Buprenorphine alone for pregnant patients) has been shown to be as much as 60% successful in treating Opiate Use Disorders, making it by far the most successful treatment protocol available. For questions about this therapy, see other articles on this topic.
In this article, we are going to walk side by side through the process of this type of therapy.
The Decision Has Been Made…
Okay, so you have been using opiates pretty hard lately. At first it was pills. Maybe you recently, say, in the last year, started doing heroin then before you know it you are injecting it. Maybe you had some recent sobriety with a relapse. Maybe you started using as soon as you got out of rehab, or maybe you are still in a residential program and going through withdrawal. Point is, you are looking at withdrawal tomorrow morning, just like so many other mornings in the past and probably more to come.
You are tired of this. It is time to do something.
The Steps For Getting Help Are:
1. Admit you have a problem that you are unable to overcome on your own. At this point, you have got this.
2. Call an Opioid Treatment Center (OTC) that specializes in Medication Assisted Treatment. You may have to call around to many offices. There is a limit on how many patients a doctor can see with this therapy, so space in these programs is at a premium. DON’T GET DISCOURAGED. If you strike out at one office, ask for a recommendation for another doctor while you are on the phone. You will eventually find a doctor, even if you have to drive a couple hours one-way every month. It’s worth it.
3. Book your Intake and Induction appointment while you have them on the phone.
4. Follow the staff’s directions to the letter. The protocol for this process is very specific. You have to be in complete withdrawal for your first appointment.
5. Complete your Induction and figure out your daily dose.
6. Book a follow up appointment within a month.
7. Begin or continue counseling
8. Take your prescribed dose every single day. This drug combination does not work the same as using. If your brain tells you that you “need” more, you do not. Your body is the one calling the shots with the drug, and you already stabilized at a specific dose. Using more than is prescribed is a sure fire way to end up short and spend several days in withdrawal ahead of your next appointment.
It will need to get just a bit worse before it gets better.
· You will need to avoid taking any kind of opiate for a minimum of 48 hours before your appointment. If your drug of choice is Methadone, you might want to consider as much as 72 hours. This will be hard. Nobody is going to say it is going to be easy. You will get through this, and you will feel perfectly stabilized by the end of your appointment.
· The induction cost can vary from $150-450 or more. You should ask if you need to be prepared to pay in cash.
· If the doctor is not licensed to dispense drugs like a pharmacy, you will be given a prescription to go and fill and return with, so if you need to get a ride to the appointment you should plan for a ride to the pharmacy. One pharmaceutical company, Zubsolv, offers a coupon for up to 15 tablets for free to ease this process. If the office is not using this brand, you will not ever need more than 3 of this type of drug for your Induction, and that can be purchased for less than $30.00.
· You will be given measured doses of the drug until your symptoms resolve.
· Expect to be there for several hours, perhaps as many as 5 hours that day.
· Your symptoms will slowly but surely resolve. If you truly have no opiates in your system for the past 48-72 hours, then at some point you will begin to feel your withdrawal symptoms going from being like a freight train right next to your ear to a car off in the distance when you are hanging out in the woods. In some people the volume is turned off completely.
· At this point the professionals know what your daily dose is to keep you stable and out of withdrawal with no cravings from your body. The mind, well that is another thing all together. That is where the counseling comes in.
Book Your Next Appointment:
Unlike Methadone Maintenance Therapy, you do not need to go to a clinic every day to get your dose. Because this medicine has a “ceiling” above which it no longer gets stronger effects, it is safe to take home up to a 30 day supply. You will leave with a prescription with enough to get you through until your next appointment.
Appointments: How Often Will I See The Doctor?
There is some disagreement among doctors on this. Some doctors want to see you every week for a while. Some doctors will feel comfortable writing you up to a 3 month supply after you have been stable for several months or years.
Standard Protocol is Every 28-30 Days.
· If the doctor observes high risk factors, they might want to see you every week for a while.
· Meeting with your doctor every month allows them to check in with you to see how you are doing. You should feel like the doctor and the office staff care about you and your recovery.
· If a doctor does not want to meet with you every month, the doctor should have assessed that you already have a lot of support in place in your life, and you should otherwise already be stable with a good job, secure housing and relationships. Since this is not very many people at this stage, maybe every 30 days is a minimum that you should look to connect with your doctor.
· In order to prescribe Medication Assisted Treatment, a doctor is bound by a special license to make sure that you are actively involved in counseling while you are prescribe the drug therapy unless you are assessed to be otherwise stable in life with a stable job, relationships and other important measures. Most patients are not at this point, so you should expect to do counseling for a while. How long? That will depend on you and the progress you are making.
· If a doctor does not require proof of counseling from you in the beginning, then your program is incomplete, and for your sake and the sake of your recovery you might want to find a different doctor.
What does this counseling entail?
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), counseling for MAT should include:
different forms of behavioral therapy as well as
and other assessment and treatment services
Counseling is your KEY TO THE KINGDOM. The medication is at best 30% of how the process works. The rest is made up of your motivation and your work with your counselor. This inner work is where the magic happens. Otherwise, you are simply drug seeking through a doctor with no plan to get off the drug. Your real work is inside your heart and head.
How often you meet with your counselor will depend on their assessment, your doctor’s recommendations and your insurance or ability to pay.
STANDARD PROTOCOL IS: Twice monthly at a minimum which is what Medicaid typically covers in many states. If you go to an agency, there may be block grant money to cover a higher level of care like Intensive Outpatient or Residential Treatment.
Taking Your Daily Dose:
You stabilized. You know exactly what keeps you out of withdrawal. You have a prescription with enough to get you to your next appointment…exactly enough. If you overuse, you will go without it at the end of the prescription. But the truth is that if you take the prescribed dose, your body does not go into withdrawal. There is no need to overuse.
You will never develop a tolerance to this drug combination and need larger doses of the drug, and there is a plan to come off of it. What is not to love?
There are several things to consider when deciding on how to take your daily dose:
Options For Daily Dosing:
Entire Dose In the Morning:
· Pro: Gets it all out of the way first thing.
· Con: Sometimes your entire daily dose can feel like too much at one time. Sometimes it can feel sedating at first, so taking it all at once can be overwhelming in the beginning.
Partial Dose at 2 or 3 Times a Day:
· Pro: Smaller doses help avoid nausea from prescription (usually goes away in time)
· Con: This represents the same drug taking behavior of taking drugs multiple times a day. This is a habit you will eventually want to break.
Entire Dose Before Bed:
· Pro: Ready to go as soon as you wake up breaking the cycle once and for all of waking up in withdrawal.
· Con: Some people say this keeps them up at night.
Your doctor will have an opinion on this, so feel free to talk to him or her about this.
There could come a time when you are ready to get off this treatment. This should be a decision made by a team consisting of:
· Your Doctor
· Your Counselor
· Most Importantly: You
When you feel that you have stabilized your life and mental health and believe that you can withstand the allure of your drug without a stabilizer and a blocker, then you are ready to wean- down off the drug. This can take a while.
STANDARD PROTOCOL: ¼ Dose Per Month or ¼ Dose every 10 days for a fast wean-down. Most people can safely tolerate theses amounts without going into withdrawal.
· The Number of Doses x 4 = Number of Months for your Wean Down.
· If you are on 3 strips, this will take a full year.
· The Number of Doses x4 = Number of 10 Day Periods for your Wean-Down
· If you are on 3 strips, this will take about 4 months.
Be patient with yourself and the treatment. It is not uncommon for this therapy to go on for 1-5 years. Engage in the work with your counselor. You are worthy of a long process to get well.