Treatment With Buprenorphine
The recovery process
brain changes of addiction are responsible for unnatural cravings.
Recovery is basically a reversal of these brain changes. This is
accomplished through a deliberate self-reconditioning processin which addiction-related behaviors are replaced with new healthy patterns of behavior. Once sufficient experience is gained with the new behaviors the
craving-causing brain adaptations may be diminishedto the point where medication is no longer necessary.
Buprenorphine suppresses cravings allowing the patients to make these big life changes.
The changes are the actual recovery, not the medication or the time on it. The ability to identify and make the changes will determine the success or failure of the recovery.
It Takes More Than Medication Alone
Unfortunately, simply taking the treatment medication isn't enough. Suppressing cravings and withdrawal alone does not reverse the brain adaptations of addiction. To prevent the return of uncontrollable cravings after discontinuing buprenorphine, the brain changes which cause them need to be addressed. If not, cravings return soon after the buprenorphine is discontinued. This is why detox treatments, particularly short detox treatments are notoriously unsuccessful. For long-term success, the craving-causing brain adaptations must be reversed, or coping techniques learned before tapering off the buprenorphine.
To give you some idea of the entire recovery process, which will vary person to person, here's a rough guide; 1
- Phase 1 (1 day - 2 weeks)
Stabilize on the medicationto suppress cravings and withdrawal symptoms. Identify and begin to
treat any co-occurring physical disorder, like HIV or HEP-C.
- Phase 2 (1-4 weeks)
Identify and begin to
treat any co-occurring psychiatric conditions, like Bipolar, depression, or anxiety.
- Phase 3 (1-2 weeks)
Build support system: peer support (Example: online forums or live 12 step), friends and family support, religion (if applicable)
- Phase 4 (1-6 months)
Change environmental factorsthat contribute to the disease. For example, if you have roommates who are in active addiction, relocate. If places, people or things trigger cravings or are associated with your drug use, make an effort to disassociate to the extent possible.
- Phase 5 (1-6 months)
Reduce sources of stress, anxiety and depressionin your life to the extent possible. Rebuild finances, repair relationships, end toxic relationships, use counseling and therapy to learn to deal with any trauma in your life. A counselor, life coach or therapist can be very helpful here.
- Phase 6 (1-6 months)
Develop new healthy patterns of behavior. This in effect rewires the brain. As you deal with normal stress and anxiety and do it without the use of drugs, you will change your reflex reaction to take drugs, to one of dealing with what is presented to you in a healthy way. While in active addiction brain pathways have been created making drug-taking your reflex reaction to stress. Dealing with stress without drugs helps reverse that brain alteration. It's this process of reconditioning that is recovery. This is a deliberate effort and doesn't just happen automatically, it's the real work of recovery.
- Phase 7 (3-6 months)
Once you have made significant changes and have experience and a track record of repeatedly dealing with stressful situations and normal life in a healthy way, it may be time to move to the
medication-free stageof treatment. At this point a slow taper is started pacing dose decreases with your brain's ability to adapt to each dose decrease. (see taper-table for suggested taper schedule)
- Phase 8
If you are able to keep the
addiction in remissionwithout an opioid supplement, you will use the cognitive tools you learned in treatment to deal with any lingering or occasional cravings or triggers. You will be able to recognize the precursors to a relapse and be armed with the techniques to intervene. Congratulations, you win!
How are the brain changes of addiction reversed?
In Phase 6, we get to the meat of the recovery process, the self-reconditioning process. Prior phases are preparation for this critical phase. This is where the craving-causing brain pathways are reversed, to the extent they can be.
To reverse the brain changes we need to first understand how they came to be. We know from the pages about the brain that the brain is constantly changing. These changes are in direct response to our actions and thoughts. 1
A Nobel-prize winning study of taxicab drivers in London showed that those who had developed the best navigation skills and had the most experience using those skills had a larger and denser hippocampus (the part of the brain thought to be used for navigation). This showed what many suspected, that the brain is physically altered by our thoughts and behaviors in measurable ways. 1
Addiction is not only a behavior but a learning process. The brain becomes conditioned and hard wired to crave opioids. Correcting this involves replacing destructive behaviors with new ones and avoiding behaviors which might reinforce the addictive behaviors.1
The recovery process is essentially a deliberate reconditioning effort where new alternative patterns of behavior are established and re-experienced. Buprenorphine's role is to suppress cravings and withdrawal so that this reconditioning process can take place.
Therapists and counselors can help create and organize an individual plan to go about the reconditioning process. It might consist of changing the environment to avoid triggers.
What specific changes you make need to be tailored to your situation. Basically, you want to end all behaviors which remind you of active addiction. Try and replace any activity which triggers memories of active addiction with new ones unrelated to addiction. Force yourself to think about something else if you find yourself reminiscing about the good-old-days of addiction.
Learning a new skill or starting a new career, are examples of how to implement the reconditioning phase.
NAABT's publication about change and how it related to addiction recovery.1
Peer support, 12-step
Peer support gives people the opportunity to discuss their concerns and the experiences with others who are also going through the recovery process or have been through it. These discussions can help create realistic expectations of this new phase of life. The camaraderie and support from peers can help a person stay engaged in treatment. Peer support is never a substitution for medical treatment.
Whether it's 12-step groups, online forums, church groups or secular support communities; peer support is different from medical treatment. The two are important but separate components of an overall treatment plan. Choosing between 12-step and medication is a false choice. People utilizing medication assisted treatment can choose a support system to go along with medication, and 12-step may be that choice for some.
12-step groups are just one of many forms of peer support and not right for everyone. Those who do find it compatible often find it very useful. Alternatively, some 12-step groups are anti-medication and have talked people out treatment only to have them relapse and die.2 Each group is different and you should visit a few of them before deciding one way or another.
Therapy and counseling
Prior to buprenorphine treatment, drug counselors mainly dealt with the management and consequences of the detox-craving-relapse cycle. Developing techniques to resist cravings and to minimize the damage from relapse encompassed the bulk of the sessions. Some of these techniques involved strict enforcement utilizing drug tests under threat of expulsion in the event of a positive test. Unfortunately, today some counselors still view addiction treatment in this way.
With the advent of buprenorphine treatment, the role of the therapist/counselor has changed. Since buprenorphine completely suppresses cravings and withdrawal, developing techniques to deal with this is not the urgent matter at hand. Instead, helping the patient identify and then change destructive behaviors, environment, and thinking becomes the role of the counselor or therapist.
Knowing what to change while in treatment is prerequisite to a successful outcome. Things which remind patients of active addiction, or cause stress, anxiety, or depression all contribute to the risk of future relapse spurred by cravings. Reprogramming the brain so that these cravings don't occur, or are greatly reduced, post treatment, is what the recovery is all about.
Successful therapy or counseling will help you identify, prioritize and begin to change the things in your life which will ultimately have an effect on the craving-causing brain structures fortified by addiction. Creating a new life which is not associated with active addiction is a daunting task that a good counselor or therapist can help guide you through.
Therapy and counseling differs from peer support in that its structure is based on evidence-based science and it is conducted by a healthcare professional.
Professional therapy can be one-on-one or with a group. Group therapy generally costs less as the cost is distributed among the participants whereas one on one is paid by the individual. Group therapy helps patients learn how others cope with similar issues, and understand common concerns of addiction treatment, at the expense of reduced privacy. One-on-one therapy focuses on the specific needs of the individual some of which they may not have in common with others.