So, there are often some frequently asked questions and some myths about these medications in particular and opioid addiction in general. So let's go back to our case of the 38 year old female who had been using heroin and cocaine IV for about 20 years, no prior treatment and had been arrested for possession, had served or sentences for both. But has some medical conditions and psychiatric conditions including Hepatitis C, depression, hypertension and diabetes. But really hadn't had any regular health care which is pretty common. She'd come into the emergency department with a headache and a very high blood pressure and uncontrolled diabetes. So, medication and which one? So her questions really were isn't taking one of these medicines just substituting one addiction for another? What will happen to me? How long do I need to take it? If I want to come off will I go through withdrawal? So as we've talked about that methadone and buprenorphine really treat withdrawal and physical dependence, and that's not the addiction. Naltrexone as an antagonist does not, but in all these cases medications and counseling is really what treats the opioid addiction. On the right dose of medication, people function normally, they're not getting high and they don't meet the diagnostic criteria for an addiction. So, what about which medicines should she take? Well, there's some national work that has been going on to really look at access to these addiction medicines, as well as how do you choose which medicine to use for which person. There is other support out there for physicians and other health care practitioners who are interested in more. In the national guideline from the American Society of Addiction Medicine, it summarizes the conclusions of a very thorough literature review, and essentially it comes down to there remains almost no evidence of any enduring benefit from these medications when used only for detoxification, but that unfortunately right now we don't know which one of the medicines is best for which type of patient or under which circumstance. That needs to be the focus of additional research. But we know that in reality and in practice not one medicine is going to work for every person. So it's good to have all three of these FDA approved medications. So, the other question that she had, our 38 year-old woman was how long do I need to take the medicine? Well, hopefully I've shown you that some of that is really individualized, and because of the data that shows us the risk of relapse is so high when people taper off, and that it takes about three to five sometimes longer than five years for relapse risks to drop significantly, that less than 90 days in any treatment setting, really is of limited to no effectiveness, and that staying on the medication in combination with counseling results in much better outcomes than withdrawing and tapering off the medication too soon. It could include decreasing the dose, but tapering completely off is what has been associated with those poor outcomes. The goal really is recovery. Well so how did we define recovery? Well people define it different ways, but some of the things that we know in terms of what are protective factors for sustained recovery after medication ends are seen on this slide, and they include housing, resolution of any outstanding legal issues, employment or education or something that gives people purpose and focus, and having managed or stable other medical and psychiatric conditions, stable and managed other substance use disorders and a really solid recovery support network. So the question of, will the person go through withdrawal where she wants to come off method on buprenorphine. Well remember, since methadone buprenorphine or opioid agonists, they do cause physical dependence, but not the same as addiction. So slow tapering of the dose is really recommended because that will cause minimal withdrawal and reduce the relapse risk. It absolutely should be done under medical supervision and monitoring, and for people in recovery who were doing well there really is no rush. So SAMHSA which is the Substance Abuse Mental Health Services Administration has a definition of recovery that I really like. They define it as a process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential. If that isn't enough for physicians or other health care professionals that the Diagnostic and Statistical Manual of the fifth edition from the American Psychiatric Association defines remission, and as you can see in number three on here that people can be in remission on maintenance therapy if they don't meet any of the other diagnostic criteria other than tolerance to or withdrawal from the agonist. So what that means is that people can be absolutely in full recovery in remission even when they're taking a medication like methadone or buprenorphine. I know that my experience with my patients has really shown me that, and that there are many paths to recovery. Not one is going to work for everyone, but if we work with people and engage with them and we really care about them, we can get people to health recovery and wellness.
