‘Recovery is too hard and dangerous. Solution: methadone for life’ by DJ Mac

w600_817157f479b2b1cb43e6a6646b8f7efcWell worth checking out excellent new blog, Recovery Review, by DJ Mac. Here’s a sample:

‘Berlin, like many big cities has a heroin problem. People presenting for help are being prescribed opioid replacement therapy (ORT) in greater numbers. That’s a good thing isn’t it? Well it depends on what you think is the end goal of treatment.

At the start of this interesting recent German paper “Why do patients stay in opiod maintenance treatment?”, Dr Stefan Gutwinski and colleagues say that the scientific literature indicates the point of ORT is: “to increase survival and bring stabilization to patients, in order to enable them to reach abstinence of opioids.” The Scottish Government’s drugs policy and the UK policy agree.

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What Works in Treatment?: Sapphire’s Story, Part 3

rsz_dscf2263We’ve been following Sapphire’s Story with a focus on the treatment she received, recognising that treatment can either facilitate or have a negative impact on the recovery process. We’ve seen Sapphire courageously overcome heroin addiction, crack addiction and most recently an addiction to benzos. There’s more to overcome.

‘Once I was off the benzos and feeling a little more like myself, I went back to work. I hadn’t worked since having the crack-induced event, so was really scared that I wouldn’t be able to cope with a job.

As I had come off the benzos, and now had the proper support of a partner and my family, I started thinking about reducing my methadone with a view to abstinence. I knew I had the willpower, as I’d managed eight nightmarish months of the benzo detox and I’d also kicked a crack addiction about two years earlier.

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What Works in Treatment?: Sapphire’s Story, Part 2

rsz_img_2115Last week, we looked at Sapphire’s Story, with the aim of showing the importance of person-centered treatment. Along Sapphire’s journey into and out of addiction, things went well when Sapphire was intimately involved in decisions about her treatment, but poorly when professionals took sole control.

We left Sapphire’s Story after the Community Drugs Treatment had reduced her prescribed methadone dose against her will and she started to use street drugs again. She eventually became addicted to crack. This drug took over Sapphire’s life, until the day she ended up in hospital: “I’m not sure what actually happened one particular day. I know that I had been up for about five days smoking crack and I think I had a fit and was taken to hospital.”

Sapphire was transferred to the drug and alcohol unit of the hospital and put on a high dose of methadone. When she left this unit, she did not go back to the controlling and abusive man she had been living with since she was 16 years old.  Her parents had found out about her drug-taking and became very supportive.

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What Works in Treatment?: Sapphire’s Story, Part 1

rsz_img_2357Sapphire’s Story shows the importance of person-centered treatment. Things went well when Sapphire was intimately involved in decisions about her treatment, but poorly when professionals took sole control. We’ll look at various stages of Sapphire’s treatment career.

Sapphire was being prescribed methadone for her heroin addiction, but as the dose was not high enough she was suffering withdrawal symptoms. To counter the discomfort of this withdrawal, she was purchasing methadone on the street and using benzodiazepines. Then a problem arose from her urine sample:

‘When I was 25, my urine screening revealed that I was taking benzos and the CDT sent me to a shared care GP who was to prescribe my methadone and benzos. At my first appointment, I decided to be honest and tell the GP about the methadone I was buying, and how bad my benzo use had become.

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Most visited content: Nos 10 – 6

rsz_img_5024And the drum rolls as we enter the top ten most viewed content on recovery Stories. 

10. Journeys into and out of heroin addiction, Part 2, is an article I wrote that focuses on living with addiction and covers such topics as relationships, changes in personality and lifestyle, hustling, crime and prison, impact on health, and treatment .

9. Opiate detox: methadone or suboxone by Peapod is the third part of Peapod’s Recovery Guide. Peapod was the most visited blogger on Wired In To Recovery.

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‘Falling From a Pink Cloud (and Learning How to Fall Correctly)’ from Zenith Chasing

rsz_unknownI can’t resist putting on another of Erica’s blogs from Zenith Chasing. This is her latest, more powerful writing. Thank you, Erica.

‘Recent events have snapped me back into reality, my pink cloud had officially dissipated, if you could even call it that…  I guess that given my predisposition towards the negative, it makes sense that my personal pink cloud would be miniature sized.  Fun sized?  I guess the latter sounds a little nicer, and chewier somehow (I’m thinking of nougat.) 

Abstract ruminations and manic tangents aside, I feel like shit.  Just found out that another friend of mine, albeit not as close a friend as T, but someone I have known since I was 17, died this week.  Rest in Peace LES Jewels – I will miss you buddy.  This is certainly the end of an era for the Lower East Side.

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Zenth Chasing: This will serve as an introduction

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This is a picture of me though I change my hair a lot so I may not look like this anymore, you get the general idea. That is my friends kitty.

This is some really powerful writing – first of her blogs – from Erica on her website Zenith Chasing. Erica contacted me this week.

The intro to the website reads: ‘A twenty-something, female, east-coast transplant, creatively inclined, dirt poor, recovering addict documents her struggles and triumphs as she claws her way towards her dream of a happy and productive life in San Francisco.’

‘I’ve been waiting for the right time to write my first post and I guess today makes sense because today I’m fucking up.  I am about to relapse, I know this yet I cannot seem to stop myself.  I’ve been trying to get a hold of my dealer since last night. He is notoriously difficult to get on the phone which is probably to my benefit right now, but I know that if he had been available I would have gotten high last night, so my current sobriety is not for lack of effort to the contrary.

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‘Opiate detox: methadone or suboxone’ by Peapod

“Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.”

This is the third part of Peapod’s Guide to Recovery, a series of articles written by Wired In To Recovery’s most visited blogger.

‘I don’t like stand alone detoxes, mostly because they almost always fail to deliver. Relapse is the norm if all you are offered is detoxification. I’ve written about this before in Detoxification: the nuts and the bolts so won’t go over old ground, but I will say again that success depends on the stuff that goes on around the detox and in the days, weeks and months afterwards.

This rough guide is written for those of you (or your clients) who might be thinking about detoxification.

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‘Standing on the outside: Looking in’ by Aurelius

P4091276‘Firstly, I want to thank all of the site [Wired In To Recovery] members who have taken the time to comment on my wife’s posts/queries (Whiplashgirlchild). Your perspective (and objectivity) have really seemed to help her on days when everything just stacks up and turns bad.

I met my partner just as she was working her way off subutex. She had a decade of hardcore use under her belt and almost another decade on MMT/Subutex.

I had (have) a lot to learn about the nature of addiction and the meandering paths of recovery. I have had a steep learning curve, trying to understand the stigma and prejudice that she has had to endure during the years of struggle to get free of ‘the fog’ as she likes call it.

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‘A Personal Story’ by Wee Willie Winkie

2007_0116walpole0097‘I’m 33 years old. I started taking drugs from ten years old and, apart from a three and a half year stint in the army, took them continuously right up to the age of 30. This included 11 years as a heroin addict.

During this time, I felt totally isolated and alone in the world, and completely worthless. After a few years I was desperate. I’d overdosed a couple of times and, at this point in my life, I’d have welcomed death with open arms. It never came, so I decided to help it along a bit.

Luckily, it didn’t work but at the time I just didn’t know what to do. Eventually, I decided that this was my life and to try make the best of it I could. I ended up living in the woods for a year. I could never see myself living in shop doorways.

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‘Opiate detox: methadone or suboxone’ by Peapod

“Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.”

“Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.”

I don’t like stand alone detoxes, mostly because they almost always fail to deliver. Relapse is the norm if all you are offered is detoxification. I’ve written about this before in Detoxification: the nuts and the bolts so won’t go over old ground, but I will say again that success depends on the stuff that goes on around the detox and in the days, weeks and months afterwards.

This rough guide is written for those of you (or your clients) who might be thinking about detoxification.

Getting ready
Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.

Let’s assume you have a package of treatment and support set up and detoxification is an early part in your journey. If you are coming off opiates then you may be offered some choices around the nature of your detoxification plan. On the agenda may be discussions around whether you should use methadone, Suboxone (or subutex) or even lofexidine to help you withdraw.

What should you choose?
NICE is an organisation which makes recommendations to the NHS based on research findings. There are many recommendations and considerations in their guidance. This blog is not an in-depth guide. It’s important that things are kept safe so speak with your prescriber.

In the NICE Opiate Detoxification Guidelines, they suggest that if you are prescribed methadone or subutex/suboxone on a maintenance basis, then you normally ought to detox on the same drug. Research indicates that neither drug is better than the other though withdrawals are over faster with Suboxone than methadone.

In practice, you’ll almost certainly get some choice around what drug to use for detox, but there’s more to think about than the drug alone. Here’s what NICE say:

“In order to obtain informed consent, staff should give detailed information to service users about detoxification and the associated risks, including:

  • the physical and psychological aspects of opioid withdrawal, including the duration and intensity of symptoms, and how these may be managed
  • the use of non-pharmacological approaches to manage or cope with opioid withdrawal symptoms
  • the loss of opioid tolerance following detoxification, and the ensuing increased risk of overdose and death from illicit drug use that may be potentiated by the use of alcohol or benzodiazepines
  • the importance of continued support, as well as psychosocial and appropriate pharmacological interventions, to maintain abstinence, treat comorbid mental health problems and reduce the risk of adverse outcomes (including death).”

How long will it take?
That depends on what sort of level of methadone or heroin or suboxone you are starting out from and also on the setting. In an in-patient unit, a detox will take less than a month generally (sometimes much faster).

In the community, it could be much longer though the guidance suggests that around three months would be reasonable. If you are doing it in the community you’ll probably have to pick your medication up daily from the pharmacy.

Methadone
Many folk have successfully completed detoxes on methadone. Withdrawals are generally not too uncomfortable with reductions at higher levels, but begin to bite a bit below thirty milligrammes. The NHS Orange Book Guidelines suggest reducing methadone at 5mg every one or two weeks. The last few mls can be problematic for many.

Methadone is generally more sedating than Suboxone but it has the advantage to many of familiarity and you don’t have to worry about moving onto a drug you’ve not tried before.

Suboxone/subutex (buprenorphine)
The main player here is buprenorphine. When naloxone, an opiate blocker is added in to reduce abuse, the combination is called Suboxone. Buprenorphine is a newer drug than methadone and it has some advantages and one or two tricky points.

The most important thing to remember is that you can’t start Suboxone when you still have significant amounts of methadone or heroin (or any other opiate) in your system because it can cause withdrawal to suddenly occur and when that happens it’s horrible. This is because opiate receptors in the body love buprenorphine and give up their methadone and heroin molecules at the drop of a hat to accommodate the buprenorphine. The sudden loss of the other opiates causes this withdrawal and there’s not much you can do about it, so it’s best to avoid the situation where it might occur.

The bottom line is that you need to have allowed at least 24 hours (often more) after the last methadone dose or eight hours after the last heroin dose before you can start subutex and the prescriber will want to see some evidence of early withdrawal just to make sure.

It’s also difficult to convert to Suboxone when you are on higher amounts of methadone. Generally prescribers like you to be under 30mls, so you will have to detox on methadone down to that kind of amount.

In some people, Suboxone causes a headache and for everyone it tastes a bit bitter (it’s absorbed from under the tongue). People commonly report a “clear head” on Suboxone compared to methadone.

The Orange Book Guidelines suggest reducing by 2mg every two weeks to start with and slowing down to reductions of 400 microgrammes towards the end. Withdrawals from Suboxone peak a few days after the last dose and get better rapidly afterwards.

Lofexidine (Britlofex)
Not an opiate, but works on a body system that turns the dial down on some opiate withdrawal symptoms. In some centres, you may be offered this alone to help with withdrawals, though it is most often added in to a methadone or Suboxone detox, usually towards the end.

It can drop your blood pressure, give you a dry mouth and make you feel a bit drowsy, but it’s quite good at taking the edge off withdrawals. Lofexidine is usually only prescribed for about a week, starting at a low dose, building up rapidly and then tailing off again. Not a good idea to stop it suddenly as your blood pressure can jump. Ask your prescriber about whether it might be helpful at some point. I don’t think it’s available in the USA.

Complicated detoxes
Where there are a few drugs in the mix, e.g. benzodiazepines and opiates or alcohol and opiates, then it’s often wise to be attending a specialist service and there’s more likely to be an in-patient admission involved.

The same might be true if you’ve had complications on detoxing before (e.g. seizures or mental health problems). If you have other medical problems or complex social issues, then a residential detox may well be best.

Down to you
Ultimately, the choice is yours. I would suggest when speaking with the prescriber or clinical staff that you ask them what they would choose in your position.

If you are asking me, it would generally be Suboxone though there would be some exceptions to this; I think people are more comfortable on it and the discomfort is over faster.

If you don’t fancy the (usually minor) discomfort of converting to Suboxone from methadone, that might be a reason to go down the methadone route.

I can’t stress enough that what goes with the detox will determine how successful you are at achieving your goals of a drug-free recovery. So many people think of the detox as being the important part. If recovery is the train journey from London to Aberdeen, then detox is the time taken to call the taxi. You need to think about the rest of the journey.

Being in an intensive treatment setting, attending mutual aid and being engaged with peer support services will increase the odds of success. The more support you have the better.

Don’t forget those harm reduction messages of loss of tolerance and risk of overdose on relapse. If you do go back to using: use less; don’t inject; don’t use alone and don’t mix drugs.

Being informed will empower you. Don’t be afraid to ask questions – remember it’s your detox. The prescriber is there to be your guide and supporter, not to dictate. Good luck!

PDF document >

Peapod’s Guide to Recovery

Peapod, now ‘retired’, was one of the most prolific and respected bloggers on Wired In To Recovery. (S)he wrote a series of must-read blogs containing important hints to facilitate recovery.

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Iain’s Recovery Story: ‘This is me’

A treatment agency helped Iain detox from the methadone that was prescribed for his heroin addiction. College, employment, recreational activities and romance facilitated Ian’s recovery.

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Bouncing Back: A Story of Resilience

I found this film on Vimeo today. I thought it is a great Story. Well done, Lisa!

‘Lisa Wrightsman, was able to Bounce Back from an addiction to alcohol, methamphetamine , and methadone by leveraging street soccer to assist her recovery and how she continues to help other women win their battle with recovery through soccer.’

Kevin and Kerry: ‘A Family Story’ (Part 1)

Mother and son describe Kevin’s heroin addiction and how it impacted on the family as a whole.

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Matthew’s Recovery Story: ‘Making most of the opportunity’

Matthew set himself up a personal recovery plan to overcome his addiction to opiates, gambling and overeating – and his life has been transformed.

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‘Detoxification: The nuts and bolts’ by Peapod

P1011113_2Why not check out the second of Peapod’s articles in his Recovery Guide, an article which focuses on detox and beyond?

‘Okay, youʼve got to the point where you are looking to detox but youʼre not sure what the nuts and bolts of it are. How do you go about it and how do you know you are ready? What can you do to boost success?

Here are my suggestions, which are based on guidance and my own experience of working with hundreds of people going through detox.’

Sapphire’s Recovery Story: ‘It should all be about the person’

Shows the importance of person-centered treatment. Things went well when Sapphire was intimately involved in decisions about her treatment, but poorly when professionals took sole control.

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