I frequently get a LOT of questions....

Why are some people more susceptible to addiction than others?

Susceptibility to addiction is complicated and complex. About 50% of one’s susceptibility is genetic, mostly related to a person’s dopamine receptors and opiate receptors in the brain. It seems that people with fewer dopamine receptors are more prone to becoming addicted to opiates because opiates stimulate dopamine release.

The other 50% of susceptibility comes from environmental and other patient factors. The presence of a mental health disorder such as depression or bipolar mood disorder greatly predisposes a person to becoming addicted to opiates. Home environment, including the presence of abuse, can pre-dispose a person to addiction. Socio-economic status and the amount of education also play a large role.

If one is addicted to opioids, what are their treatment options?

The American Society of Addiction Medicine has outlined four different levels of care for patients with opiate addition problems. These levels of care range from 1) outpatient treatment programs including individualized therapy and group therapy, 2) intensive outpatient treatment, otherwise known as IOP (9 hours a week) or partial hospitalization programs, 3) inpatient services such as inpatient rehab and 4) medically managed inpatient services for those patients who also need medical stabilization. Usually an addiction treatment provider can perform an initial intake on a patient and determine what level of care the patient needs. Many patients can do just as well with outpatient treatment as with inpatient.

In addition, patients with opiate use disorders have two basic options:

Option 1 Patients can go on to medication assisted therapy (MAT), also known as opiate replacement therapy (ORT). With this option a patient is converted to either methadone or buprenorphine. Both of these medications are opiates, however, they do not produce the “high” that patients typically feel with traditional opiates like oxycodone or heroin. Methadone and buprenorphine can be long-term solutions, and being on either of these medications for years causes very little major problems.

Furthermore, being on MAT greatly reduces relapse, reduces the incidence of communicable disease (believe it or not, patients with opiate use disorders frequently inject their drug of choice intravenously and frequently use “dirty” needles, contaminated with hepatitis C or HIV). Stopping MAT greatly increases the risk of relapse.

Methadone used for patients with opiate addiction can only be prescribed by licensed methadone treatment facilities. So taking methadone for opiate addiction can be cumbersome – the patient has to typically go to the methadone clinic every day for their dose of methadone. This is because methadone is a very strong narcotic, and can be abused by patients and can lead to overdose.

Buprenorphine was approved for use in the treatment of opiate addiction in 1982. It is a “partial” opiate, so it is safer to use than methadone. It much less frequently leads to overdose and patients typically cannot get a full euphoric effect from it. Simply put, it mainly prevents the horrible withdrawal symptoms patients get from stopping opiates. Since it is safe, the DEA has allowed physicians to prescribe it in their offices, once the provider has gone through a special training class. Providers can prescribe enough buprenorphine to last for several weeks to several months.

Buprenorphine also comes in an implantable form. The buprenorphine implant can be placed under the skin of the upper arm and will provide a constant amount of medication for over 6 months and in most cases much longer, even up to a year. This greatly helps patients in that there is no daily medication to take.

Option 2 Patients can use medication to stop using opiates completely. Typically patients are given medications to make going through withdrawal from opiates more comfortable. When patients abruptly stop opiates they typically go through withdrawal, which can include severe muscle aches, severe agitation, nausea, vomiting, and diarrhea. Doctors can use medications to minimize these symptoms. After the withdrawal period is over (typically in about 5 to 7 days) patients are started on naltrexone therapy. Naltrexone is an opiate blocker. It blocks all the effects of opiates. Naltrexone comes in extended release intramuscular injectable form, which lasts in the body for 28 days. So as long as the patient comes in for the injection every 28 days, the patient is “protected” from the effects of opiates, both the euphoria effects and the harmful effects. And naltrexone greatly reduces cravings for opiates. Naltrexone also comes as an implant that can last in the body for 2 to 6 months, depending on the implant, conferring to patients a much longer period of protection from opiates.

How do you specifically work with patients?

I am an outpatient addiction treatment specialist, focusing only on the outpatient treatment options, including medications as well as therapy.

I use both options listed above. I treat patients with buprenorphine including the oral, daily buprenorphine, the newer monthly injectable form called Sublocade, and the buprenorphine implant Probuphine.

I also provide the option of getting a patient off of all opiates and onto long-acting naltrexone, including both the intramuscular 28-day naltrexone as well as the naltrexone implant.

In addition I provide an accelerated outpatient “detox” program. Patients trying to stop their opiate use are typically going to go through a severe withdrawal syndrome for up to 7 days. We use a combination of 7 medications to make patients much more comfortable during the “detoxification” period as well as to shorten the period to 3 to 4 days.

Why are doctors still prescribing opioids if we now have an epidemic?

Opiates are appropriate medications when used correctly. They should be used to manage acute pain after injuries or surgeries, but should not be used on a longer term basis. It takes less than a week to become addicted to an opiate when it is used on a daily schedule. So opiates should be only taken for several days and then discontinued.

Also, chronic pain due is a real problem. Many patients do have chronic orthopedic pain or cancer-related pain that needs to be treated with opiate medication. And many patients do well on long-term opiate medication without developing addiction. These patients do develop dependence, meaning they can’t stop the medication or they will go through withdrawal. But these patients can function normally, go to work, have normal social relationships and do not show the typical signs of addiction.

What is the first step someone with an addiction should take once they’re ready to acknowledge they have a problem?

Patients should seek help. There is currently no central location to look for help, so patients need to be resourceful. A good idea is to probably get the help of a trusted friend of family member. Addicts frequently are not thinking clearly. Find a trusted person to help. Look online for addiction treatment providers. Understand that outpatient treatment has been proven to be equally effective as expensive inpatient treatment.

Patients should not try to stop using opiates on their own. While typically not life-threatening, withdrawing from opiates without medical assistance is dangerous and extremely uncomfortable.

I am currently working with the Colorado Society of Addiction Medicine to develop a page on their website that can explain treatment options to patients, outpatient versus inpatient, detox, recovery, individual vs. group therapy. Addiction versus dependence. These terms are so foreign to most people. Having a trustworthy centralized source of information and treatment options will be helpful.

Explain the term “dope sick.”

Patients who become addicted to opiates do so in order to get the “high” that opiates initially provide. They keep coming back to the opiate to get the same high, but that initial high is harder and harder to achieve because patients become tolerant to the effects of opiates. In other words, it takes more and more of the same drug to achieve the same level of euphoria. But patients don’t just develop this tolerance to opiate, they also develop “dependence,” meaning the brain has essentially been hijacked by the opiates. The opiates change the brain’s chemistry such that once this happens if the patient does not take their daily dose of the opiate the patient is going to go through withdrawal.

Eventually, after prolonged use of opiates over months, the patient stops getting the “high” that they initially achieved with the opiate, and start using the opiate just to prevent becoming “dope sick.” Dope sick is really just the severe withdrawal symptoms that patients experience when their body has developed a dependence on the opiate. It includes severe agitation, anxiety, body aches, and muscle spasms. It also can include severe vomiting and diarrhea and sleeplessness. Patients will do anything to avoid becoming dope sick, including finding easier opiates to use, such as heroin.

Let’s talk about the government’s declaration of an opioid epidemic. What’s changed since the announcement?

The government has relaxed its rules on how many providers can provide buprenorphine. It has expanded treatment prescribing of buprenorphine to physician assistants and nurse practitioners. It has offered grants and subsidies to treatment providers to get the mandatory training class that is needed in order to be able to prescribe buprenorphine. The government also regulates how many patients a treatment provider can have on buprenorphine. Previously the limit was 100 patients and the government has expanded this now to 275 patients. So it is trying to make access to buprenorphine, one of the mainstays of Medication Assisted Therapy (MAT) easier for patients.
I suspect that we are going to see more grant monies coming from federal and state resources to additionally help with the crisis.

State legislatures are also paying more attention to the crisis. In Colorado, according to the Denver Post, opiates kill someone in Colorado every 9 and ½ hours. According to the same article Colorado received an additional $35 million to be put towards solutions for the epidemic. Some of that money is going to research. I suppose we first have to understand the problem in order to try to fix it.

Some of the legislation currently being considered in Colorado is to have prescribers limit the amount of days of opiates given to patients to less than 7 for patients that have never taken opiates before. Also having prescribers be required to check the State’s database, the Prescription Drug Monitoring Program (PDMP) to see a patient’s history of opiate prescriptions. Finally the State is considering giving prescribers “report cards” to see how their prescription patterns align with other prescribers.

Why do we have an epidemic in the first place?

This is complicated and not easy to sort out.

Pharmaceutical Companies:
15 years ago drug companies who made prescription opiate medications were telling providers that the medications they were making were not addictive.

Government:
The Joint National Commission, the organization that accredits hospitals and facilities, and CMS (Centers for Medicare and Medicaid Studies) added “Pain” as a vital sign in 2001. So in addition to measuring a patient’s blood pressure, pulse, temperature, respiratory rate, etc. providers, hospitals and facilities were mandated to treating a patient’s pain. Providers, hospitals and facilities who did not do that were looked at unfavorably. CMS even continues to have patient satisfaction scores related to pain and will adjust reimbursement levels to providers based on how well a patient’s pain is treated. Not surprisingly with this linkage of pain treatment to reimbursement, providers began to treat pain more aggressively, and also not surprisingly, this is when the opiate epidemic started.

Economic Crisis: In 2007/2008 the economic crisis hit the country really hard. Many people were out of work and looking for an easy way to make money. For many pain pills were the answer. Patients on state-sponsored Medicaid programs can get prescriptions of opiate pain medications for $2 - $3 per month. Imagine, go to your doctor and get 60 oxycodone 10 mg tablets for a total of $3. Each pill can be sold for $10. The whole bottle can be sold for $600! It is an easy scam for patients to pull off at the doctor’s office. Chronic back pain, chronic orthopedic problems. Government telling providers to treat the patient’s pain. Pharmaceutical companies telling providers the medication is not addictive. This was easy money for a lot of patients. Throw in unscrupulous providers who would prescribe more opiates than required and this was and in some parts of the country continues to be a recipe for disaster.

Heroin is usually what an addict will go to next. Why? How is it the same and how is it different from opioids?

Heroin in cheap. It comes directly from the poppy plant which is grown extensively in Mexico, so it is easily transported to the US. It has a very rapid onset of action and a short half-life and is converted very quickly to morphine and 6-acetyl-morphine, both of which are powerful narcotics. Drug dealers from Mexico have set up elaborate distribution systems. The dealers are nice, well-dressed and frequently give free samples. They have learned that customer service goes a long way towards keeping people addicted to heroin.

How do we fix the crisis?

It is going to take a concerted effort on the part of many parts of our society, including government, medication prescribers, law enforcement and schools. We need to provide more education to middle school and high school kids about the perils of becoming addicted to opiates. Providers need to change prescribing behavior to give fewer days of pain medication and educate patients on the dangers of opiate use and how quickly addiction and dependence develop. Providers also need to check urine drug screens and check the PDMP on a consistent basis to look for irregular patterns of drug use by patients. Governmental agencies need to allow more providers to treat patients for opiate use disorders and need to provide more funding for relatively inexpensive outpatient treatment options. We need to educate providers and addicts about the benefits of long-term naltrexone therapy as a way to prevent relapse. Law enforcement needs to continue to do its job of reducing supply of illicit drugs including heroin, fentanyl and others.

It sounds like recovery is a long process, and costly. How can people get help both emotionally and financially?

Recovery is lifelong. I haven’t met an ex-opiate user yet who hasn’t told me that. Coming off of opiates can be costly if done in an inpatient treatment center. But it doesn’t have to be. Outpatient withdrawal symptoms management has been proven to work just as effectively as inpatient, and costs much less. Ongoing recovery can be emotionally draining but it doesn’t have to be expensive. There are Narcotics Anonymous and Smart Recovery groups. Phoenix Multi-Sport offers exercise-based recovery group meetings. All of this is free. Ongoing naltrexone therapy does have an expense but much less than ongoing opiate use. Methadone and buprenorphine used in MAT programs can also have a cost, but again, much less so than continuing with opiate addiction.

Benzodiazepine Addiction? We can help!

Benzo Picture.png

Where do you want to start? If you are like many of my patients, roll the dice and pick one. Caffeine? Chocolate? Alcohol? Valium? Opiates? Let’s start with a class that is one of the most dangerous. Benzodiazepines.

Benzodiazepines like Valium came on to the market in the US in 1959 and were commonly prescribed as the cure for emotional problems. In fact, by the 1970’s and early 1980’s benzos had become the most commonly prescribed class of drug in the entire world. Despite what we have learned about benzos over the past 30 plus years they continue to be one of the most widely prescribed classes of medication.

You’ve probably heard of most of these medications: Xanax, Valium, Klonopin, Ativan. There are others as well. Patients most commonly use them for anxiety and muscle relaxation, though there are other uses as well. These medications are easily abused. In fact, in 2010 there were close to 500,000 emergency room visits for involved benzo misuse or abuse, with abuse rates second only to narcotic pain relievers. As with narcotic pain pills, benzos are one of the most commonly used medications involved in drug-related suicide attempts, and the most commonly involved benzo involved is Xanax (alprazolam).

Abuse and misuse of this class of medication is common. MUCH MORE common however is benzodiazepine dependence. Once you start, you just can’t stop. Mostly this is due to the withdrawal symptoms patients get when they try to stop. These symptoms include an uncomfortable increase in heart rate, severe agitation and anxiety, insomnia, irritability and tremor. Withdrawal can even include seizures, delirium and death.

No one wants to withdrawal from benzos. It is extremely uncomfortable and can be dangerous, even life-threatening. Most of the time the only option presented to patients is a long and slow taper. This can take several months, even up to a year. During this entire period the patient is going to have waxing and waning uncomfortable withdrawal symptoms. Studies have been done on the effectiveness of taper programs and the data are discouraging. Most patients cannot taper. Perhaps there is a better and quicker way….

Enter flumazenil. Flumazenil is a benzodiazepine receptor antagonist/partial agonist. That is a mouthful, and the easiest way to think about how flumazenil works is that is attaches to the same receptor in the brain to which the benzos attach. In doing so, it competes with the benzodiazepine medication for that receptor. It is a unique substance in that it can remove the dangerous benzodiazepine from the receptor and at the same time activate the receptor to prevent severe withdrawal symptoms from developing. Patients can safely discontinue benzodiazepines abruptly and be administered flumazenil for 7 to 8 days as well as an additional anti-seizure medication for about 4 weeks. With this protocol patients can more easily and more successfully cease their use of dangerous benzodiazepines.

ARCH Detox has adopted the use of this benzodiazepine discontinuation protocol with the goal of providing a more successful way for patients to stop using these dangerous drugs. We are having great success with this protocol which was developed by Dr. Peter Coleman of The Coleman Institute in Richmond, VA. For more information, please reach out to us at www.ARCHDetox.com, or visit www.TheColemanInstitute.com.

ARCH Opens NEW Ambulatory Detox Facility

ARCH Detox announces the opening of a new two bed outpatient/ambulatory detox facility in Aurora, CO. Patients are able to receive outpatient detox services for opiates, alcohol and benzodiazepines with one-on-one nursing support and an on-site physician at all times. Outpatient/ambulatory detox costs about 1/3 what a typical inpatient detox stay would require. During the outpatient detox the patient will also be set up with ARCH Detox's ongoing recovery treatment program with individualized therapy by our licensed psychologist, Dr. Dwight Duncan, and will also be set up for ongoing medical support by our addictionologist, Dr. Nathan Moore.

ARCH Detox uses several outpatient protocols for alcohol detoxifcation including phenobarbital and librium. Alcohol detoxification can be life-threatening, so it is important to have well-established protocols, continuous cardiac monitoring and one-on-one nursing support.

For opiate detoxification, ARCH continues to use the Coleman protocol, utilizing micro-dose naltrexone, followed by monthly naltrexone injections or a naltrexone implant.

"We have seen tremendous success for our patients utilizing micro-dose naltrexone. Even patients on methadone, who take up to 100 mg daily, are able to detox from methadone to ongoing naltrexone very comfortably."

Feel free to contact us at anytime to learn more about our detox protocols.

ARCH Detox Adds Day Room

Detoxification from alcohol or opiates is not a pleasant experience and it is not unusual to go in to the hospital for this type of treatment, where a patient is administered an iv, iv medications as well as oral medications. ARCH Detox has developed protocols that allow safe and effective detoxification and withdrawal symptom management as an outpatient in our Day Treatment Room. A patient comes in to our clinic and spends the entire day being monitored on a cardiac monitor and is given iv medications to control withdrawal symptoms in a comfortable environment. Our Day Treatment Room has a standard hospital bed, a comfortable recliner/rocker for a support person, television and internet access. One on one staffing with our experienced LPN ensures that every need is met. Lunch is provided through our detoxification protocols. We welcome you to call and speak with our team to get more information about our treatment programs.

How Much Does It Cost?

It is not surprising that there is a cost for treatment, detoxification and recovery. These services are usually not free, unless sponsored by a non-profit or state-run service. What does it cost? How much is it worth? The website www.rehab.com offers a great breakdown of the cost of inpatient rehab services. It is interesting to note that a study is referenced that looked at what patients perceive as the most important thing about a rehabilitation program. The thing that mattered the most to patients is cost. So let's be honest, all of the "amenities" offered by a rehab facility, such as swimming pool, spa therapy, equine therapy, etc. are really not that important. A patient and their loved ones want a patient to get well, and to get well at the most affordable price. Not surprisingly, these inpatient rehabilitation facilities suggest that a patient can be treated in a certain time frame, 30 to 90 days. But this is not realistic. Substance use disorders need to be treated over the long term. This has been studied and is proven. Why go to a 30 or 90 day "detox" or rehab when the problem is a chronic one?

ARCH Detox can and will offer you exactly what you need. A program that actually works for the long term at a fraction of the cost of inpatient rehab. Complete and physician-supervised medical detoxification and withdrawal symptom management. Ongoing therapy/counseling with our behavioral health team. Proven results. 12 months of therapy with brief interventional modalities proven to work in randomized trials. This what ARCH Detox offers.

JAMA Report Updates Opioid use in the United States

he United States is in the midst of an opioid overdose epidemic. Between 1999 and 2010, prescription opioid–related overdose deaths increased substantially in parallel with increased prescribing of opioids.1 In 2015, opioid-involved drug overdoses accounted for 33 091 deaths, approximately half involving prescription opioids.2 Additionally, an estimated 2 million individuals in the United States have opioid use disorder (addiction) associated with prescription opioids, accounting for an estimated $78.5 billion in economic costs annually.3 Proven strategies are available to manage chronic pain effectively without opioids, and changing prescribing practices is an important step in addressing the opioid overdose epidemic and its adverse effects on US communities.

See the entire upate from JAMA here.

Accelerated Opiate Detox

ARCH Detox's accelerated opiate detox program is going extremely well. Patients are detoxifying from opiates in three days with minimum withdrawal symptoms. Our withdrawal symptom management protocol is keeping patients comfortable and mostly symptom free. According to Dr. Moore, "as long as patients can remain free of the most severe symptoms, they will succeed with this program and be able to go on to long-acting naltrexone, which is the goal." Long-acting naltrexone blocks opiate receptors in the brain and allows the brain to start healing. Along with a good recovery program involving counseling and group meetins, patients with opiate addiction can succeed and go on to live productive and healthy lives.

Testimonial From Patient

I just want to thank you for your help and understanding through this difficult time in our family. Because of people like you, us and our children will have a good life now. Anyway, I just want to let you know that I haven't seen him look better than he does now in a long time. He's very motivated and he's been doing great. he still has thoughts in his head and he's open about it. However he is still struggling, but he's ready to do this and I'm glad that you're the one he went to for help.

ARCH Joins with The Coleman Institute for Accelerated Opiate Detoxification

Media Contact: Andrew Blake Executive VP and Chief Operating Officer 804.353.1230

FOR IMMEDIATE RELEASE

THE COLEMAN INSTITUTE ANNOUNCES NEW AFFILIATE IN DENVER COLORADO

Richmond, Virginia (June 15, 2017) – The Coleman Institute announced today its partnership with Dr. Nathan Moore of Denver, CO. A nationally recognized leader in opioid addiction treatment, The Coleman Institute is proud to have Dr. Moore join their team of experienced addiction treatment professionals. As a new affiliated medical practice, Dr. Moore and his team will offer a full range of treatment services including Accelerated Opiate Detox, Naltrexone therapy and long-term care planning.

Board-certified through the American Board of Family Medicine, Dr. Moore completed his undergraduate work at Stanford University, and then attended the Duke University School of Medicine, obtaining his M.D. in 1995. Dr. Moore went to Colorado to complete his residency and has stayed in the area, providing comprehensive family medicine services at his MedNOW Clinics, founded in 2014. He has taken a special interest in addiction medicine, treating patients with opioid use disorder, as well as alcohol and other substance use disorders, at his Addiction Recovery Centers for Healing known as ARCH Detox.

Dr. Peter Coleman, founder and National Medical Director for The Coleman Institute stated, “Dr. Moore’s philosophy of medically supervised detoxification followed by an individualized long-term care program fit perfectly into our unique treatment model. The Coleman Institute’s focus has always been to help patients get clean and stay clean through evidence-based treatment services, and to offer those services to as many people as possible. Our partnership with Dr. Moore serves to further that mission, and we hope to work with him bring hope and recovery to those in need in the Denver area.”

The Coleman Institute’s programs utilize medically supervised detoxification to comfortably and safely control the physical symptoms of withdrawal that can make recovery from opiate addiction challenging, if not impossible. The combination of detoxification and after-care support, including Naltrexone therapy, provides patients with a comprehensive, individualized treatment plan offering the real possibility of experiencing long-term sobriety.

Dr. Moore noted, “We are pleased to be able to add another medically competent treatment option to our services offering at ARCH Detox. The growing need for services to combat substance use disorder is staggering, and partnering with The Coleman Institute was a natural extension of my continuing efforts to offer compassionate, effective options for recovery.”

To meet Dr. Moore, visit: https://thecolemaninstitute.com/locations/denver-colorado

For more information on The Coleman Institute, or to find a location near you, visit: www.TheColemanInstitute.com

About The Coleman Institute:

Established in 1998 in Richmond, VA, The Coleman Institute has developed a unique and customizable approach to assisting patients in overcoming their physical dependency on drugs and then accessing the long-term support resources needed to maintain their sobriety.

Since its inception, The Coleman Institute has helped thousands of patients detoxify and recover from the effects of heroin use and other opioids such as OxyContin, Percocet and Vicodin. The Coleman Institute’s treatment program enables over 98% of its patients to successfully complete their detox and begin Naltrexone therapy.

The Coleman Institute has 11 offices nationwide (Richmond, Atlanta, Austin, Cherry Hill, Metro Chicago, Denver, Phoenix, Seattle, Tampa, Southern California, and Northern California).