The majority of patients struggling with opioid use disorder are most interested in and best served by medication-assisted treatment modalities in combination with biopsychosocial clinical services. Though the success rate is typically very low, Sunrise does offer a counseling-only program, too. Patients interested in a counseling-only experience may be earlier in their disease process and not require the support of medication to get them into recovery. Others may have tried medicated-assisted treatment previously and had a negative experience. Some patients may struggle to appropriately self-administer treatment medications and not qualify for ongoing medication assistance or have access to alternative medication formulations. A few patients will pursue inpatient or residential care first before transitioning to outpatient, and a number of those programs do not initiate medication-assisted treatment as part of or after their detoxification process. With that, patients coming from those settings may try to continue treatment without medication. Sunrise's counseling-only approach would include individual counseling with or without intensive outpatient group counseling. In either scenario, participation in additional community-based recovery groups and connecting with sponsors and other peer supports would be encouraged.
Sunrise primarily provides maintenance treatment with buprenorphine products in a chronic disease model of care for patients struggling with opioid use disorder. However, Sunrise can also provide short-term detoxification utilizing buprenorphine products over a period of 4-8 weeks on a case-by-case basis. The following are a few examples of such situations that may warrant short-term detoxification:
Reported or known misuse of treatment medications without access to alternative formulations
Long-term treatment with pain medications with physiologic dependence referred by provider who is inexperienced with discontinuing narcotics and managing the associated withdrawal syndrome
Actively using or on other treatment medications and leaving to an area without access to ongoing care
Actively using or on other treatment medications and facing incarceration with no ongoing care
Due to cost constraints and challenges with insurance formularies, Sunrise primarily utilizes generic Suboxone (buprenorphine/naloxone) tablets in its medication-assisted treatment program. There are other buprenorphine/naloxone formulations that may be used for various reasons to include the sublingual Suboxone film, buccal film (Bunavail), and brand-name tablets (Zubsolv). As a partial-agonist, the buprenorphine only activates the opiate receptors to ~40% of their full potential. That’s just enough to eliminate the withdrawal symptoms and help a person to feel stable and normal. That also comes along with a “ceiling effect” when it comes to impact on the respiratory system, which means that it is nearly impossible to overdose on this medication when taken as directed. The naloxone in Suboxone is the chemical in the opioid overdose reversal medication, Narcan. When taken as directed, the naloxone has no activity in the body. If misused, though, the naloxone is likely to induce some amount of withdrawal symptoms. Given these features along with its slow-onset of action and long-acting properties makes buprenorphine/naloxone an ideal treatment medication.
Buprenorphine tablets without naloxone (Subutex) are only available for certain clinical situations to include induction, pregnancy, and documented allergic reaction to naloxone-containing formulations. A buprenorphine-only film is also on the market (Belbuca). As mentioned above, when taken inappropriately, naloxone-containing formulations make the patient feel uncomfortable as some amount of withdrawal is induced by the naloxone. The naloxone has no ill effect when taken as directed. This pharmacologic property is one of the key reasons why Suboxone was approved to be prescribed for treatment under the federal DATA 2000 Act.
For patients who have difficulties self-administering their treatment medications, long-acting, buprenorphine-only formulations may be warranted for use. These can also be helpful for people looking for additional ways to break their daily physical routines of self-administering anything. Additionally, long-acting formulations can possibly make for an easier tapering off process at the end of treatment. Currently available formulations included the monthly injectable Sublocade, and the 6-month implantable Probuphine. Both of these formulations are exceptionally expensive and require prior authorization from insurance providers.
Oral and long-acting injectable formulations of naltrexone are also a medication-assisted treatment option for opioid use disorder that Sunrise provides. Neither have been shown to be as effective as other modalities (i.e. methadone and buprenorphine products). The oral formulation of naltrexone (Revia) is particularly challenging to comply with and very few people get into recovery using this option. The monthly injectable naltrexone (Vivitrol) doesn’t primarily treat opioid use disorder, but rather the prevention of relapse to opioid dependence following opioid detoxification. There are additional challenges with Vivitrol in that a variety of other non-narcotic medications have to be utilized to help a patient to abstain from opiates for anywhere from 3-14 days until such time that the first dose can be administered. If given too soon, the naltrexone will send the patient into immediate and severe opioid withdrawal. For this reason, less than half of patients desiring this treatment make it to their first injection. Additionally, naltrexone does not activate the opiate receptor to any degree, so patients oftentimes continue to require the support of other medications to manage their post-acute withdrawal symptoms. Half of the patients who receive their first injection typically discontinue treatment prior to receiving their second injection. For those that make it to their second injection, success rates are similar to patients treated with buprenorphine. Given the expense of Vivitrol, prior authorizations from insurance companies also have to be obtained.
Though Sunrise understands the need for medication-assisted treatment with methadone and supports it as a treatment option, we are not certified to provide treatment with this medication.
Narcan contains the chemical naloxone, which can reverse the effects of an opioid withdrawal. Narcan has no other known actions in the body, no other known side effects, and no other known drug interactions. With that, it is safe to administer in the event that someone is found unresponsive and won’t hurt the person even if they’re not experiencing an opioid overdose. Given these chemical properties and the prevalence of opioid use disorder in our communities, everyone is encouraged to carry a Narcan kit and Good Samaritan laws protect anyone who administers Narcan to a possible opioid overdose victim. Sunrise provides Narcan to each of its new patients at intake.
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