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The basic feature of these treatments is the provision of a prescribed medication to enable you to feel comfortable and not experience withdrawal, or to prevent cravings and further drug use, while you concentrate on making the big lifestyle changes that entail becoming drug free. There are a number of different types of maintenance medications. For alcohol dependence there are two main pharmacotherapies:
Both of these treatments reduce cravings and reduce the risk of relapse after a slip (that is, you are less likely to continue drinking once you have had a first drink if you are on these pharmacotherapies). Acamprosate may be preferred for longer-term use. (Antabuse is now rarely used, as the side effects are more severe than with use of acamprosate or naltrexone.) For heroin dependence there are four different pharmacotherapy treatments at present in Australia (we have not included LAAM or diacetylmorphine (heroin) as neither of these is available):
The pharmacotherapies work in different ways. Drugs such as heroin, morphine, methadone and codeine that bind to opiate receptors and produce an opiate effect are termed 'opiate agonists'. The more drug that is taken the more the effect. Drugs such as naloxone and naltrexone that bind to opiate receptors and produce no effect are termed 'opiate antagonists'. These drugs block the effects of agonists. If these drugs are taken in high enough amounts they will replace agonists that are bound to the receptors. If this happens the person may experience withdrawal symptoms that can be quite severe. Buprenorphine is a partial agonist or an agonist/antagonist, it binds to opiate receptors but only produces a partial opiate effect. If the opiate receptors are vacant, buprenorphine will produce an opiate effect. If the receptors are occupied by a full agonist (such as methadone or heroin), the person may experience withdrawal symptoms. These withdrawal symptoms are generally not as severe as those brought on by antagonists. Suboxone is the brand name of a new medication for treating people dependent on heroin or other opiates, such as morphine. Suboxone is similar to buprenorphine in that it is a sublingual tablet (dissolves under the tongue) but it has naloxone added to it to prevent it being injected. Buprenorphine is like methadone, but it can be taken every second day (rather than daily) because it lasts longer. It is a tablet, dissolved under the tongue. There are side effects of buprenorphine - ask your doctor about the relative advantages and disadvantages of this drug. The Subutex (i.e. buprenorphine) treatment guide produced by the company that makes the drug explains more about the action and effects of buprenorphine. It is available free from treatment centres and many other agencies. When you start a buprenorphine program, you will probably be advised about the risk of OD if you combine it with other drugs or alcohol. See Chapter 3, What Causes a Drug Overdose?, for more information. Like methadone, buprenorphine is a drug that binds to opiate receptors. It has a stronger attraction for opiate receptors than methadone and can replace other opiates that may be occupying those receptors, such as heroin or methadone. Buprenorphine only partially stimulates the opiate receptors, so that even if most of them are occupied by buprenorphine, it only produces mild opiate effects. The effect of this is that most people feel more clear headed with buprenorphine than with methadone - in fact some people say that they feel a bit 'speedy'. With buprenorphine, higher doses do not produce much more effect than lower doses, but the effect lasts for longer. Some people find that if they double their daily buprenorphine dose, they feel comfortable for twice as long. In this way, many people can pick up every second day or three times a week. Like methadone, the higher the dose, the less people feel like using heroin, and the more the effects of heroin are blocked. Because buprenorphine produces these partial opiate effects, it is particularly useful for detoxification from opiates that produce stronger effects like methadone, morphine and heroin. Using buprenorphine every day for five to 10 days, most people find they are able to comfortably withdraw from opiates at home with no other medication needed. Methadone is administered every day as a syrup, and makes the person feel comfortable, without cravings. It does not produce a rush and most people just report feeling 'normal' (and often a bit sedated) on the pharmacotherapy. With methadone, the dose you take determines how comfortable you feel. Generally speaking, the higher the dose, the more comfortable people feel, the less people feel like using heroin. The effects of heroin are blocked by higher doses of methadone. There are side effects of using methadone - you will need to talk to your doctor about whether this treatment will be suitable for you. There are new rules for take aways for methadone that you should ask your doctor about when you both agree you are stable. Suboxone was developed in the US in the 1990's as a treatment for opiate dependence. Because it contains naloxone, which causes severe withdrawal if injected, soboxone is very unpleasant to inject. (Naloxone (Narcan) is an opiate antagonist, which means it blocks the brain's opiate receptors. This means it blocks any opiate effect. If you dissolve suboxone under your tongue as prescribed the body will not absorb the naloxone and it will not have any effect.) This means suboxone is safer take away medication for treating opiate dependence. It also means a more normal life is possible for opiate dependent people who want substitution pharmacotherapy. There are great information booklets available from any treatment centre that explain the benefits of this type of medication in more detail. This will help you understand the best questions to ask your doctor before making the decision to go on suboxone. Naltrexone is used to treat heroin dependence because it blocks the effects of heroin, but it does not produce any euphoria or sedation. Naltrexone appeals to those people who are committed to total abstinence and are willing to self-medicate with naltrexone every day (you are given a script for a course of naltrexone and don't need to attend a pharmacy every day). Like buprenorphine, naltrexone is a drug that has a strong attraction for opiate receptors, however it produces virtually no opiate effect. With enough naltrexone on opiate receptors, it is virtually impossible to feel the effects of other opiates. Taking a 50mg tablet of naltrexone each day generally provides enough naltrexone to effectively block other opiates. Most people who are initially attracted to the idea of taking naltrexone tablets find that they stop taking them after a while, either because they feel they do not need them or because they want to feel the effect of opiates again. During this period many people start using heroin again and are at high risk of overdose because they have no tolerance for opiates. For this reason people have developed naltrexone implants. There are a number of naltrexone implants and long lasting naltrexone injections available in Australia, but all of them are relatively new and at time of publication they have not yet been approved by the Therapeutic Goods Administration, the government body that approves all medicines and therapeutic devices. Studies need to be done to determine the safety and effectiveness of these devices. Preliminary evidence indicates that they can be effective for some people; however, there are problems that have been identified. These include infection and allergic responses around the site of insertion and severe withdrawal symptoms if the implants are inserted prior to opioid detoxification. The implants can induce intermittent or partial opioid blockage, meaning that some people will resume heroin use but at higher levels than before. This can be a problem and some people need to have their implants removed so they can start methadone or buprenorphine. The implants are generally active for three to six months, depending on their size. It is likely that the amount of naltrexone delivered by these implants will be less than taking a 50mg tablet each day. Over time, the effects of the implants wear off and people may be able to feel some effect of heroin again. Some people find that in this period they can still feel the effects of heroin if they use a lot. This can be a problem and some people need to have their implants removed so they can start methadone or buprenorphine. This must be done surgically, as the implant is quite deep beneath the skin and over time it becomes stuck to the surrounding body tissues. The time when the implant is removed is a high risk one for overdose as the body has no tolerance to opiates. While some people have found them useful, naltrexone implants are still at the experimental stage and a number of clinical trials are expected in the near future.
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