‘Maintenance drugs’ remain hot-button issue in recovery

This is the second in a periodical series of recovery options in Warren County. No recovery program is one size fits all, and no one uses only one method to successfully recover. Successful recovery from addiction requires wise choices in resources, and the ability to share information between the different elements that a person is choosing to make use of in his or her recovery process. The series will examine not only the different elements of successful recovery programs that are available within the county, but when those individual pieces of a larger recovery puzzle may be indicated and useful, and when they may not.

Part of what prevents people from entering recovery is anxiety over withdrawal.

Whether it’s the physical withdrawal symptoms or the emotional reaction to them, the prospect of getting off a substance can feel insurmountable, and is often the barrier to entering recovery that keeps people who struggle with addiction actively using. This is where “maintenance drugs” like methadone and Vivitrol can come in handy, said local providers. There are passionate opinions in both directions on the topic of medication-assisted recovery (MAR). Regardless of which side a person leans toward on the issue philosophically, the fact remains that prolonged drug and alcohol use creates physical changes in the structure and function of the brain, and that removing drugs of long-term abuse from the system is going to have an impact on the physical systems of the body, as well as the mind. Those impacts can derail what might otherwise be a successful recovery plan, or even prevent it from getting off the ground in the first place.

First of all, it’s important to understand the difference between an opiate and an opioid. Opiates are drugs made from the naturally-occurring ingredient molecules found in opium poppies, and include drugs like opium, morphine, and codeine. They can be manufactured drugs with legitimate medical uses, but opiates ultimately derive from poppies, in every case.

Opioids, on the other hand, are synthetic or semi-synthetic manufactured molecules created in laboratories for the purpose of creating drugs that treat pain in medical patients. Common opioids include OxyContin, hydrocodone, and fentanyl, among others.

The distinction may seem petty, but it is an important one, because maintenance drugs are opioids, not opiates.

Most people are familiar with the concept of methadone. Chemically similar to opiate medications and illicit drugs like heroin, methadone and the fairly newer answer to methadone’s drawbacks, Suboxone, partially block drugs of abuse from causing the euphoria that contributes to addiction once they enter the brain. While methadone is a full opiate agonist, and effective at preventing physical withdrawal symptoms, it is also easier to abuse and more likely to be diverted – sold, given, or traded illegally among communities of drug users. Suboxone is a partial opiate agonist, meaning that it lights up the same brain structures responsible for the euphoric effects of opiate drugs, but it has a point at which those effects plateau, and in binding to those receptors in the brain, Suboxone prevents users from gaining the euphoric effects of opiates after having taken it, thus increasing the likelihood that users will stop using illegal opiates and commit to Suboxone itself. Suboxone is a combination of buprenorphine, the agonist agent, cut with naloxone – the generic name for the popular drug Narcan – which reverses the effects of overdose with drugs like heroin. Suboxone is three parts opiate agonist and one part naloxone, meaning that not only does it reach a plateau, reducing motivation for abuse, but it also helps prevent the dangerous side effects of opiate use such as respiratory depression that carry with them the risk of overdose.

Of those two drugs, Suboxone is the safer and less divertable choice, said local physician Dr. Mason Tootell, who is currently the only provider of MAR services in Warren County. But better than both of those, he said, is the even newer injectable drug Vivitrol.

While both methadone and Suboxone are given on a daily or every other day basis, said Tootell, Vivitrol is given in the form of a once-a-month injection, making it impossible to divert. It is also chemically the opposite of opiates and opioids. Rather than stimulating the parts of the brain that cause the euphoria and sedation most responsible for opiate addiction, said Tootell, Vivitrol is an opiate antagonist. It blocks the parts of the brain responsible for addiction from being activated by drugs of abuse. It is not possible to get high on Vivitrol, so it is also free from the risk of intoxication or abuse. Vivitrol, said Tootell, is a “very, very safe drug” for the person in recovery to take advantage of when relapse becomes an issue.

According to Deerfield Centers for Addictions Treatment (DCAT) Program Director and Clinical Supervisor Jake Boston, the demographic of recovery can “often be looked at in terms of thirds.” One third of people in recovery, said Boston, will successfully stop using on their first try with relatively few issues. Physical withdrawal, he said, is essentially like having a “really bad flu,” and this group of people will be able to get through it with the same over-the-counter assistance that someone with a virus might use. The second group, he said, struggle through recovery at first, and may relapse a time or two before eventually being successful as well. And a third group of those in recovery, he said, will struggle with lifelong relapse issues throughout the duration of their recovery journey. That second and third group, said Boston, are the people who may benefit from a maintenance medication like methadone, Suboxone, or Vivitrol as one component of a successful recovery plan.

But MAR, said Boston, “is not for everyone,” and figuring out who might benefit from it, as well as wisely determining which maintenance medications are going to be most efficacious case-by-case is just one part of what a reputable MAR program will provide. There are disreputable providers of maintenance drugs, just as there are disreputable prescribers of opiate and opioid pain medications, said Boston, and as with all things in healthcare, it boils down to money. Maintenance medications are expensive.

According to the National Institute on Drug Abuse, the estimated per-patient cost of methadone as of last year was around $4,700 annually. But that’s not what it costs the patient. Because methadone is not filled a pharmacy but rather dispensed at program locations like clinics, the providers of each program set the price-per-patient and it can vary widely from provider to provider. Suboxone programs, also, are priced by providers, with the costs to take advantage of any given program going between $100 to $350 per month, on average. Vivitrol, said Tootell, can go for $1,500 an injection.

The good news for most people in need of a MAR program, said both Boston and Tootell, is that insurance companies – especially Pennsylvania Medicaid programs – see the benefit of covering the programs rather than having to deal with the sequelae of addiction, which can include the disease risk that comes along with intravenous drug use, overdose, and crime. That $100 to $350 a month can take the place of a $100 to $350 a day drug habit for users, and can prevent insurance companies from eventually seeing the exponentially higher costs of active addiction on the part of their insured being passed on in the long run.

In the case of private insurance, said Boston, many companies cover the drugs once deductibles are met, and some programs offer significant copay assistance offers, to help put a dent in otherwise unaffordable deductibles for those who need it. Furthermore, said Boston, most private insurances will cover the medical end of an MAR program – the drug itself and maybe the clinical appointments with prescribing physicians – but not always the behavioral components, like substance abuse counseling that any reputable medication-assisted program will entail.

So long as a person’s insurance covers maintenance drugs, and so long as providers accept a person’s insurance, MAR can, in fact, represent an affordable alternative to active drug addiction, and one way to overcome the user’s biggest barriers to treatment – psychological ambivalence and fear of withdrawal experiences.

Once MAR programs get those users stabilized, said Tootell, and in a place where thinking and decision-making is not being dictated by intoxication and drug-seeking to maintain it, that’s when the behavioral and psychiatric components of the program can take increasing roles in that person’s recovery journey. Often, said Tootell, without the maintenance medication, an addict will never get to or be able to stay in a place at which substance abuse counseling, support programs, and accountability will be useful or available in their continued sobriety.

“These medications in and of themselves don’t represent sobriety,” explained Tootell, but rather a viable route toward sobriety for a particular demographic of actively addicted people. Ultimately, agreed both Boston and Tootell, individual differences in personality and circumstance will dictate whether MAR is indicated or contraindicated for any given person in or considering a recovery program.