The price of addiction: A treatment primer for opioid dependence

From the Portland Business Journal, October 9, 2013

There are a lot of unsung heroes working in the trenches in Portland to help those who have fallen into opiate dependence.

Alison Noice, director of addiction medicine treatment at CODA, is one of them. CODA is the oldest opioid addiction treatment program in Oregon, established in 1969 as part of a state effort to provide methadone treatment.

The clinic in Northeast Portland dispenses methadone to more than 400 people a day. CODA also has transitional housing, outpatient, residential, detoxification and recovery centers in Gresham and Tigard.

CODA's Alison Noice discusses treatments for opioid dependence.

CODA’s Alison Noice discusses treatments for opioid dependence.

[Portland Business Journal writer Elizabeth Hayes] sat down with her recently to ask some questions about treating opioid addiction, which is a huge public health issue in Portland and Oregon. The problem often starts with legitimate use of painkillers and then snowballs or even becomes heroin use.

Hayes: If someone is addicted to opioids, what are their treatment options?

Noice: Someone addicted to opioids could seek treatment in an opioid treatment program, in other words, a methadone clinic. They could receive buprenorphine (Suboxone) treatment either through a primary care physician or through an opioid treatment program. They could seek treatment in an outpatient setting that didn’t include medications. They could seek treatment in a residential setting. Really it’s about how severe is the dependence, what other needs does that person have, what’s their social functioning, what does their environment look like?

Hayes: Under what circumstances would you recommend inpatient?

Noice: You’re looking at the whole person. The person we recommend be in a residential treatment really has very little support internally or externally.

Hayes: Do opioid addicts typically go to a detox facility first?

Noice: Not if we’re going to put them on methadone or Suboxone. On the day we first give one of those to somebody, we expect them to be in withdrawal, so we ask that they not have used for 24 hours. But to be appropriate for the medication, this is somebody who has been using daily that generally still has opioids in their system. One thing that’s important to realize is that the cycle of craving and withdrawal is so very intense that treatments that don’t include medications are often less successful.

Hayes: How effective is abstinence treatment?

Noice: I would never recommend cold turkey. The research shows that straight detoxification, even medically supervised, without subsequent treatment is not effective.

Hayes: Why is that?

Noice: It’s the mechanism in the brain that drives the opioid dependence. The part of the brain that opioids affect is the part that drives some of our most basic functioning, our motivation, our pleasure — not just the happy kind. This is what gets you up in the morning and makes you put on your shoes. The body produces its own opioids, but when you start introducing opioids from outside of the body, it very quickly becomes dependent on this external source. The opioids have essentially hijacked your brain at that point.

Hayes: Can you explain what methadone is and how it works?

Noice: Methadone and Suboxone both are considered opioid replacement therapies. Essentially, the methadone is going to keep that person’s brain stable. When you introduce methadone into the system, it lasts for 36 hours, so that person can focus on living. It keeps the person out of that cycle, alleviates the cravings and suppresses symptoms of withdrawal. If they’re on methadone and use other opioids, there’s some amount of blocking. If you’ve got somebody who’s opioid dependent and you put them on methadone, they don’t get high.

Hayes: How regulated is the distribution?

Noice: It’s very regulated. The methadone bottles are connected to our dispensing machine, which is integrated into our electronic medical records, so we have a lot of regulation that governs how we bring methadone into the clinic, how we inventory it and track it. For us to treat somebody with methadone, they need evidence that they’ve been dependent on opioids for at least one year. They have to have tried other treatments and been unsuccessful. We’re expected to check all the methadone clinics within a hundred miles to see that the person isn’t enrolled somewhere else. We have to do a physical examination. It’s a very structured process. You start them on a low dose. You gradually build them up, so it can take up to a couple of weeks before we’ve stabilized them on methadone.

Hayes: Do they take it every day?

Noice: If not taken every day, you’re not going to get all the benefit from the methadone that you should.

Hayes: Is there any process to wean them off methadone? Is that the goal?

Noice: It depends very much on the person and their progress. When somebody’s been dependent on opioids for a long period of time, they have potentially done long term, if not permanent, damage to their brain. You often don’t know how much damage until you get them stable.

It’s better to get them on the medication and out of the dangerous behavior — the high-risk sex, the criminal activity, the injection drug use — and help them build a safe recovery network and then look at taking them off the medication. Some folks we can take off and they do great. For some folks, the symptoms of dependence return, so at that point, it makes more sense to keep them on than to put their life at risk.

Hayes: Do some patients have to be on it the rest of their lives?

Noice: Yes. Some studies say 60 to 85 percent of people return to opioid use off the medications. Part of it is the long-term changes to the brain always put people in a place where they’re more vulnerable to relapse.

Hayes: Do people ever overdose of methadone?

Noice: Overdose deaths associated with methadone are typically not from methadone that’s been prescribed by a methadone clinic.

Hayes: Where are they getting it?

Noice: It’s been diverted. Somebody decided to sell it instead of taking it or it got stolen. Part of the regulations are they have to have a locked box to keep it in and have a plan for where it stays in the home, so it’s away from children and nobody else has access to it.

Hayes: What percentage of your methadone clients are heroin addicts?

Noice: We pulled a six-month subset of admissions from 2012 and 78 percent of admissions were heroin and 22 percent were using pills. What’s exciting about where we are with treatment options is that there are actually three medications that are approved to treat opioid dependence. You have methadone, which we’ve had for more than 40 years, Suboxone and now there’s a new formulation of naltrexone, a 28-day injectable medication called Vivitrol, which is an opioid blocker. We’re not quite there in terms of everybody having the same access to all these medications.

Hayes: Why is that?

Noice: We’re approved to provide all those medications but they’re not all covered the same way.

Hayes: Are there disclosure requirements for people on methadone who are applying for job?

Noice: Not for the employer. If the employer is somebody who requires drug testing, typically that employer contracts out with a laboratory. So if somebody’s prescribed methadone, they should tell the laboratory that’s doing the test that they’re prescribed methadone. That information doesn’t get to the employer, it’s not relevant, they’re not required to disclose it. It’s a protected health condition.

Hayes: What would make the most impact in bringing down the opioid addiction rate in Portland?

Noice: If we could make all of these medications more available and more acceptable, I think we have the potential to have a very significant impact. There is clear evidence that all of these medications work for individuals who are opioid dependent. However, limited understanding, stigma and sometimes clear misinformation all contribute to these medications not being available in ways that will benefit the most individuals

Hayes: Is it hard to see these people going through this?

Noice: When you’re in the middle of it, the small successes can be grand, like that day somebody was confronted by their old dealer and they said no, that’s huge. It’s a very slow process, as you accumulate those moments until somebody has a solid recovery. Those smaller moments can sometimes be outweighed by when things go poorly. But there are so many opportunities for those small victories. When you see somebody come into treatment addicted to opioids and eventually is able to regain custody or their child or finish school or get a job, those are amazing things to see.


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