bclearmd

It generally includes counseling online, either group-based or individual. It also includes online visits with a doctor, PA, or NP, who specializes in addiction medicine and can provide medical treatment with buprenorphine (Suboxone). Of the 3 effective medical treatments for OUD, buprenorphine is the one that can be accessed and provided safely online.

That sounds adaptive! Congratulations on your long-standing recovery, and thank you also for sharing your experience with others through your work as a social worker. In my experience, I find that patients who have been on Suboxone effectively in the past with no intolerance, almost aways will continue to tolerate the medication well when there's a need to resume it. I've not observed any sort of acquired intolerance, at least not in sufficient numbers to suspect it's at all common. I have known many patients who are in stable, successful remission of their opioid use disorder, or their tobacco use disorder, to experience revulsion or even nausea, sometimes sweats or hives, when in the presence of a strong trigger or the drug they've previously moved on from. I think this likely has to do with the strong emotional association between the trigger and the pain that the drug previously caused, when the person has moved beyond the positive, euphoric feelings that were once associated with that drug use. I can only speculate though. I do advocate strongly for use of medication for opioid use disorder (MOUD), previously referred to commonly as MAT. Effective, appropriate use of these medications is what's going to turn the corner on the opioid crisis. The need is just incredible.

I love this article that gives a thorough review of the risk of diversion or misuse of treatment for opioid use disorder and puts it in perspective.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800751/

Also beautifully well-stated by korndog42.

Methadone is extremely tightly regulated (when used for addiction treatment) so it's less commonly diverted or misused because it's less available. Buprenorphine (Suboxone) is more widely available so will be found more commonly on the street, but it also has much lower harm potential than methadone when used recreationally or as self-directed treatment. There will be more stories of misusing buprenorphine from the street and having a bad experience, but you'll hear the stories because the experience is survived. You won't hear many stories of mixing street methadone with fentanyl because it's extremely lethal.

Wow that's an interesting question. I'm not aware of any inherent, or genetic, endogenous opioid deficiency condition. I think it's worth considering that opioids themselves have no primary effect at all on the body or mind (that we know of) Their effect is completely dependent on activation of the opioid receptor, which then causes a series of direct and indirect effects in the body. So when considering where someone's "normal" opioid homeostasis, or set-point, level is, we don't look at the amount of opioid in the body but the relative level of opioid receptor activation compared to that person baseline level of activation. A person who uses opioids frequently will actually have fewer, and much less responsive, opioid receptors than others as the body is working to adapt to the super-high amount of opioids typically present - So in the withdrawal state, the baseline level of activation is so high (because of tolerance), that a "normal" state of activation for a non-tolerant person is truly a severe opioid deficiency for that person. We know this severe opioid deficient state last 3-7 days after stopping exogenous opioid use before the body starts to adapt to the new, more normal set-point, by increasing receptor numbers and sensitivity again, but some residual level of deficiency (usually felt as fatigue) often continues for months. What that opioid receptor activation level looks like decades later has never been studied, but we do know that return to problematic use, even decades later, has a strong tendency to devolve very quickly into every-day habitual use, so ongoing support, trigger avoidance, a plan in the event of developing risk of return to problematic use, is important lifelong.

I can't say how much I appreciate your trust in our program. There's a really good editorial that describes discontinuation of care for opioid use disorder that I think says it better than I'm able: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2019.19121245

The long and short of it is that many folks understandably look for an end to treatment, a point where you can say you're recovered and can be done. What we find, very consistently is that patients have a very strong tendency to return to old habits following discontinuation of medical treatment for OUD. Not always immediately, but eventually, often during times of grief or stress which come up eventually for everyone. These rates are close to 100% when treatment is stopped within a month, 50-80% when stopped within a year, and stay consistently above 50% even after 18 months of treatment. And the consequences of a return to illicit use, "relapse," are often devestating, so best practice, not just for our program but all high-quality addiction medicine programs, is routinely not to recommend stopping care. That said, just like a very small percentage of patients can successfully control their blood pressure with exercise and weight loss, with diligence and a lot of support, patients who strongly wish to move toward stopping medical treatment sometimes can. That process looks like first assessing the social causes or prior illicit use and anticipating possible triggers for return to use, and making sure those are very well-addressed in a stable, sustainable way, then developing a plan to slowly taper down the medication, being attentive for risk factors that may pop up, until discontinued. Upon discontinuing buprenorphine, there is another medication called naltrexone (Vivitrol) that is a long-acting monthly injection that can prevent overdose in the event of a return to illicit use, but it's not an opioid at all like buprenorphine so can feel more liberating for some patients.