Psychopharmacology

How Medication Can Help Prevent Opioid Relapse

Soaring Overdose Deaths Mean It’s Time to Use Every Tool at Our Disposal

Posted Aug 12, 2016

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If a person who has quit drinking relapses, they’re likely to wake up with remorse and a hangover.

If a person who has quit using opioids like prescription painkillers or heroin relapses, they may not wake up at all.

It’s a frightening reality that must be recognized when you or someone you care about tries to overcome an addiction to opioids: Recovery comes with unique overdose dangers.

That’s because when a person stops using opioids, their body begins to lose the ability to tolerate the drug, and they can easily misjudge how much they can safely consume. What used to be a moderate dose may now be enough to prevent the brain from signaling the body to keep breathing. Compare that to the dangers of alcohol, which are substantial but usually take time to accumulate.

For opioid users, there’s another troubling truth: Even after successful treatment, few opioid users are able to remain continuously abstinent during the first year of recovery. The Australian Treatment Outcome Study puts the number at 14%. 

Opioid use will usually lessen after treatment and lives will improve, but, realistically, most people have at least one lapse in them. And one time can be all it takes to kill. The first two weeks after someone stops treatment are the peak time for overdose, when tolerance is low but new patterns of healthy behavior aren’t yet engrained.

Turning to Medication

So how do we stop potentially deadly overdoses in those early days and help people live long enough to make it to successful opioid recovery?

Increasingly treatment programs are sending clients home from opioid treatment with naloxone, known under the brand name Narcan. It’s an opioid antidote, a rescue medicine that is available for self-administration as a nasal spray or an injectable

The real focus, however, should be on preventing overdose in the first place.

We can help do that by identifying those at greatest risk of relapsing and making sure they have access to every tool at our disposal, including medication-assisted treatment (MAT) such as the use of naltrexone injections or buprenorphine, which have been shown to make relapse less likely. A 2015 long-term study, in fact, found that half of those who received MAT for addiction to pain relievers were abstinent 18 months later.

Naltrexone works by blocking the intense high from opioids, which mutes the attraction of using heroin or prescription painkillers. A long-acting injectable formulation known by the brand name Vivitrol lasts a month at a time, which can prevent most overdoses and ensure the person’s commitment to continuing the treatment.

Buprenorphine is a semisynthetic opioid that helps keep painful withdrawal symptoms at bay while prompting much less of a high. Instead, the person feels normal and is able to work, have successful relationships and contribute to society. 

It comes in two forms, Suboxone and Subutex, as well as a small implant called Probuphine, which is placed under the skin and continuously releases buprenorphine for six months at a time.  

Buprenorphine works on the brain’s opioid receptors, the same ones that respond to opioids used recreationally, such as heroin and OxyContin. For this reason, some in the recovery community do not feel that people on buprenorphine are fully abstinent. Despite these reservations, buprenorphine reduces the risk of overdose among patients who take it as prescribed.

For some, buprenorphine presents a transition between the active phase of their addiction and recovery. For others who have more entrenched addictions, the drugs may be needed long-term to prevent relapse. How long someone should stay on buprenorphine is a difficult question to answer that sometimes requires a trial of tapering it under medical supervision. 

Predicting Overdose Risk

A number of factors have been associated with a higher risk of opioid overdose, including:

  • A previous overdose, particularly if it happened within the last six months.
  • A history of injecting drugs rather than taking pills — and the more frequently the person injected, the greater the risk.
  • A history of using cocaine in addition to opioids. Researchers looked across the spectrum of drug types and found that cocaine stood out for its ability to increase impulsivity and arousal and contribute to poor judgment. Alcohol was found to increase the risk of relapse but not of overdosing.
  • A history of criminal behavior beyond drug use.
  • Intense cravings.
  • A reluctance to embrace change.
  • Those with one or more of these factors are at a higher risk of overdose than others with opioid addiction. Clinicians need to ensure that high-risk clients and their loved ones are educated about the various treatment options.  

Overdoses now account for more deaths than car crashes. There are MAT options that are compatible with a range of treatment philosophies. We now need to ensure that clients with opioid dependency receive clear, consistent and universal recommendations for life-protecting medications as part of their treatment.