Treatment:Assisted Detox + Naltrexone Maintenance
Assisted DetoxIf you have found that you are unable to just stop using Percocet, we can TRY to make it tolerable (not fun or comfortable). The following steps are required:
At your first doctors visit, the doctor will prescribe medications to help reduce the symptoms of withdrawl.
The doctor will ask that you stop using for 24 hours. You should be experiencing withdrawal at this time. You can take the baclofen and the clonidine to get through the 24 hours. These pills can lessen the severity of withdrawal.
- Baclofen for muscle discomfort and sleep.
- Clonidine for sweating, anxiety, and sleep.
- Diphenhydramine for sleep
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 except the use of the medicines prescribed, baclofen and clonidine, and 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
- 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.
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 will be asked to provide a urine sample so we can confirm any use of opioids and possibly other drugs. You may also need to have blood drawn: blood analysis is important for detecting any health conditions (such as anemia or hepatitis) that might interfere with your Suboxone (or subutex) treatment if not addressed.
The goal of induction is to switch you from your current opioid (Percocet, methadone or a prescription painkiller) on to Suboxone (or subutex). You MUST arrive for your induction already experiencing mild-to-moderate opioid withdrawal symptoms. This point cannot be emphasized enough. If you take Suboxone before you are in withdrawal, the medication will make you feel worse because it can cause withdrawal symptoms.
We will assess your withdrawal symptoms and give you your first Suboxone (or subutex) dose in the office. Patients can begin to feel some relief within 20 minutes, although the full effects take about an hour, at which point your symptoms will be reassessed. We may suggest that you pass the time in the waiting area or by taking a short walk and returning to the office at a specific time. Depending on the extent to which the first Suboxone (or subutex) dose suppressed your symptoms, we may decide to give you a second dose.
When you are ready to leave the office after your first induction visit:
- We will make arrangements for you to have Suboxone (or subutex) to take home. Typically, we will give you a prescription for the amount of Suboxone (or subutex) that you will need until your next appointment, along with any special instructions related to your care
- We may also prescribe other medications to help control withdrawal symptoms
During induction, daily appointments are not uncommon. This allows us to adjust for your withdrawal symptoms and cravings. Induction can last anywhere from 2 to 7 days. Urine drug screening at every visit is also fairly standard during induction. Patients whose Suboxone (or subutex) dose may be too low often use other drugs to try to suppress the withdrawal symptoms and cravings; we look for this when evaluating whether a patient is at the right dose.
Intake and induction may both occur at the first visit, depending on your needs.
During stabilization, your Suboxone (or subutex) dose is "fine tuned" about once a week, as needed. The goal is to find a dose where your withdrawal symptoms and cravings are suppressed, and you experience minimal to no side effects. We will discuss your treatment options going forward, specifically, maintenance versus medically supervised withdrawal.
Once your dose is stabilized, the maintenance phase of treatment begins. During maintenance, your treatment compliance and progress will continue to be monitored.
Participation in some form of behavioral counseling is strongly recommended to maximize the likelihood of your treatment success. We will discuss counseling options that meet your needs.
We may request urine samples from time to time. We find urine testing a helpful part of treatment because by verifying the absence of opioids in your system we can evaluate the effectiveness of your Suboxone (or subutex) dose. Talk with us if you have questions about the role of urine testing in treatment.
During your ongoing maintenance treatment, we will want to know if you experience any cravings. If you do, your dose may need to be adjusted.
Appointments are usually scheduled on a weekly basis, however, if treatment progress is good and goals are met, monthly visits may eventually be considered sufficient. The maintenance phase can last anywhere from weeks to years—depending on what you, we, and, possibly, your therapist or counselor determine is best for your individual needs.
Medically Supervised Withdrawal
Length of therapy is up to your us, you, and sometimes your therapist or counselor. In this phase of medically supervised withdrawal, we will slowly taper your Suboxone (or subutex) dose, taking care to see that you experience minimal withdrawal symptoms or cravings. Your dose can always be changed if you experience uncomfortable symptoms or cravings at the reduced dose.