Treatment:Assisted Detox + Naltrexone Maintenance
Assisted DetoxIf you have found that you are unable to just stop using heroin, we can TRY to make it tolerable (not fun or comfortable). The following steps are required:
Stop using opiates (Heroin, Percs, Oxys, etc.)
Wait at least 24 hours. You should be experiencing withdrawal at this time.
After at least 24 hours, inject buprenorphine just under the skin, (not IV). It should make you feel better IF you waited the 24 hours since your last dose of opiates. Otherwise, you may go into withdrawal and there is nothing to be done but wait for the discomfort to subside. Do not take more buprenorphine or opiates until another 24 hours has elapsed.
Repeat the dose every 24 hours. Inject the buprenorphine once a day (every 24 hours) for three days. Inject the whole amount in the syringe. Do not divide the dose.
RETURN TO THE OFFICE after the THREE buprenorphine injections are completed. There is no charge for this visit. You will receive additional medications depending on what symptoms or problems that you are having. For the next three days, we have medications for:
- Belly pain and cramps
- Nausea and vomiting
- Restless legs and twitchiness
On the 7th day clean, since you last used any opiates, take the naltrexone capsule. It is to be taken at home at least four hours prior to coming into the office for injection of a naltrexone pellet. Many patients take the capsule the night before the pellet is to be injected.
The capsule will change the color of your urine to bright ORANGE. A urine sample will be checked before a blocker will be injected.
You MUST be clean before you take naltrexone or you will get VERY sick. The withdrawal is WORSE than any you have ever experienced. It is recommended that you be clean for 7-10 days to prevent this from happening.
An injection of naltrexone, may be administered to patients prior to receiving a pellet. If you are clean 7-10 days, or if you are taking naltrexone, there will be no effect from this injection. If NOT, in about 10 minutes you will start getting sick. It will wear off in about an hour, but we will not put in a pellet.
We require that you take a naltrexone capsule at home before coming in for a pellet.
Naltrexone MaintenanceView Naltrexone Pellet Insertion Video
Naltrexone is a medication developed over 40 years ago by Harold Blumberg (US Patent No. 3,332,950) working for the Endo Pharmaceutical Company in Delaware; the same Endo Pharmaceutical Company that makes Percocet. Like naloxone (Narcan), which was developed by the same people four years earlier as the antidote for opiate overdoses, naltrexone is an opiate blocker. While naloxone is an injectable medicine for use in an emergency, naltrexone was developed as an oral medication for long term maintenance use in opiate addiction.
Early on there was some concern about hepatotoxicity (liver toxicity) which has proven to be unfounded over the years.
Naltrexone, originally approved by the FDA and marketed as Trexan to treat opiate addiction, did not prove to be very useful because patients were non-compliant: they didn't take the medication as prescribed. In 1994, the FDA approved the use of naltrexone for the treatment of alcoholism when it was shown that it reduced cravings. It has been marketed as Revia and is prescribed to be taken as a 50 mg tablet every day, or 100 mg (two tablets) on Monday and Wednesday and 150 mg (three tablets) on Friday. Any opiates take during this time would be entirely ineffective.
About 10 years ago a naltrexone pellet was developed. It was noted that patients prescribed naltrexone after Rapid Opiate Detoxifications (ROD) had a relapse rate of 33% in the month following detoxification. The naltrexone pellets were noted to provide significant naltrexone blood levels for an extended period of time. The technique for making the naltrexone pellets last for an extended time was patented and the patent, US Patent No. 6,203,813 - Pharmaceutical delivery device and method of preparation therefore - was licensed to make them available to patients in need of a long acting naltrexone preparation, in accordance with FDA regulations on compounding. A pre IND meeting was requested. The meeting package was submitted and minutes of the meeting were made available.
In June of 2006 Vivitol, another long-acting naltrexone preparation became available. It has been approved by the FDA for use in the treatment of alcoholism, but is also used off-label to treat other conditions, most commonly, opiate addiction. The Vivitrol injection is essentially a slurry of micro-pellets of a polymer material that have been impregnated with naltrexone. The micro pellets have been described as being like chocolate chip cookies where the cookies are made of the polymer and the chips are made of naltrexone.
The polymer is the same material that has been used in absorbable suture material. Its use in providing long acting drug delivery was developed by Elie Nuwayser in Boston for which he received U.S. Patent No. 7,041,320 - High drug loaded injectable microparticle compositions and methods of treating opioid drug dependence.
This polymer has also been used to deliver naltrexone over a long period of time (six months or more), by George O'Neil of Perth, Australia. A similar preparation is reportedly available in China. These preparations consist of 5 to 10 large pellets of the polymer impregnated with naltrexone.
Before you begin treatment, we will ask you questions about your medical health history, your mental health history, and your substance use history, including your current opioid use. There are no wrong answers to these questions—the goal is to be sure that we have accurate information so we can create a treatment plan that meets your needs. All the information you give will be held strictly confidential.
You will be advised that Suboxone and Subutex withdrawal lasts at least 2 weeks and it is recommended that you remain on the medication for at least 1-2 years.
During this visit, we will go over the pros and cons of Suboxone (or subutex) treatment. Your treatment expectations, as well as our expectations of you, will be discussed. You may be asked to provide a urine sample so we can confirm any use of opioids and possibly other drugs.
- Stop using opiates (Heroin, Percs, Oxys, etc.)
- Wait at least 24 hours. You should be experiencing withdrawal at this time.
- After at least 24 hours, take the Suboxone or Subutex as directed. It should make you feel better in about 20 minutes, IF you waited the 24 hours since your last dose of opiates. Otherwise, you may go into withdrawal and there is nothing to be done. It is not dangerous, just ugly. Do not take more Suboxone or Subutex or opiates until another 24 hours has elapsed.
Expect to be on the medication for about 1-2 years during which time you will be attending meetings to learn how to stay clean and sober.
Monthly prescriptions are provided. During maintenance, your treatment compliance and progress will continue to be monitored.
We may request urine samples from time to time.
Appointments are usually scheduled on a monthly basis; however, if treatment progress is good, you are attending meetings, and have a sponsor, prescription refills may be available. Prescriptions are for a one month supply and no more than 5 refills will be provided.
Medically Supervised Withdrawal
Withdrawal or detoxification is very difficult and the symptoms last at least 2 weeks.