To understand addiction, one must first define addiction. The understanding of addiction has evolved significantly over the last two decades and recently led to a new definition as published in 2011 by the American Society of Addiction Medicine (ASAM), the authoritative US society of physicians specializing in addictions:
The short definition of addiction:
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
For the long definition of addiction, see: ASAM Definition of Addiction
How does addiction differ from drug abuse and misuse?
Medication Abuse and Misuse
These two terms are widely used, yet their definitions are as varied as there are individuals using them. The unfortunate consequence of this is a grave lack of understanding regarding their incidence, risks and consequences. Whenever reading an article or publication, try to identify the specific definition the author uses to define substance abuse or misuse for a better understanding of the meaningfulness of statements or conclusions made.
For the purposes of this web site, in statements attributed to Dr. Ehlenberger, the following definitions apply:
“Medication Abuse” is defined as the use of a drug for purposes other than as indicated or prescribed. “Purposes other than as indicated or prescribed” include using a medication such as a pain medication for sleep, anxiety, to improve mood or to get high, rather than strictly to relieve pain.
“Medication Misuse” is defined as the use of a drug for purposes as indicated or prescribed, but at doses other than as indicated or prescribed. For example, taking a pain medication 5 or 6 times/day for pain when prescribed only 4 times/day for pain would be considered “misuse.” Medication misuse also includes taking a prescription medication as previously or routinely prescribed, but without a current prescription.
(Suboxone, Zubsolv, Bunavail, Probuphine)
Key to Links:
Grey text – handout
Red text – another page on this website
Blue text – Journal publication
What is the basis, or root cause, of addiction?
ASAM’s new “Definition of Addiction” shifts away from focusing on the psychological element of addiction to redefining addiction as a neurological disorder and an imbalance in the brain’s “reward circuitry,” referred to as ‘Reward Deficiency Syndrome’ (RDS). While earlier descriptions of addiction placed the burden of addiction on “weakness of will” and other personality “deficits,” we now understand that the nature of addiction lies in disrupted or compromised neural processes.
“Reward Deficiency Syndrome (RDS),” a term first coined by Ken Blum in 1995, can now be defined as “A brain reward genetic dissatisfaction or impairment that results in aberrant pleasure seeking behavior that includes cigarette smoking, other addictive drugs, excessive food, sex, gaming/gambling and other behaviors.”
These other behaviors include an array of disorders, such as ADHD, Tics, Tourette Syndrome, autism, Asperger Syndrome, OCD, “perverted” sexual practices, binge eating and others. The relationships of these disorders becomes apparent with the understanding of the common genetic factors underlying them.
Associated with this new definition and understanding of addiction is a major paradigm shift in our approaches to treatment.
Management of Opioid SUD at Accurate Clinic – the Short Story
We recognize that the treatment of opioid SUD requires an individual approach. Not everyone is in the same stage of recovery and not everyone’s background and experience calls for the same approaches to relapse prevention. We emphasize to our patients that they will get out of our program what they put into it. We offer a great deal to those who choose to invest in our education and services. We recognize that some individuals have been in stable remission for years and may require minimal support from us. On the other hand, we also believe that we have a lot to offer everyone with an opioid substance use disorder (SUD), regardless of their level of knowledge and experience. Our treatment approach involves three arms:
Medication Assisted Treatment (MAT)
The backbone of opioid addiction, or substance use disorder (SUD), treatment involves the use of medication (Medication Assisted Treatment or MAT) to assist in detoxification and to avoid relapse. Our MAT program for opioid SUD is limited to buprenorphine (Suboxone, Zubsolv or Bunavail) or naltrexone because of licensing limitations with respect to methadone. At the initial visit, our patients are usually started (or continued) on buprenorphine to manage opioid withdrawal and begin the road to recovery and prevent relapse. In some cases, naloxone can be offered as another option. An alternative treament approach can also be considered using Synaptamine (see below).
Counseling and Education
After the first appointment/meeting with our physician, each patient is provided with a follow-up appointment with our licensed addiction counselor (LAC) at which time a treatment plan will be devised to meet the patient’s individual needs. Each patient will see our physician once a month for assessment of medication management and education about RDS and the neurobiology of addiction, including alternative approaches to treatment
Patient treatment plans include individual sessions with our LAC, provided every 1-3 months depending on the patient’s needs. These educational sessions include training in cognitive behavior therapy (CBT) and other techniques to provide our patients with the knowledge and tools to avoid relapse and return to a normal, functional life.
Group sessions are also generally advised, including those with an outside counselor, AA/NA or other 12-Step meetings including faith-based programs., online education courses, counseling with the physician, and relapse prevention-oriented handouts provided to stimulate further thought. Not everyone will require any or all of these approaches – it will be determined based on the patient’s needs, resources, experience and other variables.
Complementary and Alternative Medical (CAM) Management
We recognize that the backbone of MAT is buprenorphine, but we also encourage our patients to learn more about Reward Deficiency Syndrome (RDS) to better understand the neurobiology of addiction, including the role of genetics. Understanding RDS provides a greater ability to treat opioid SUD in a more fundamental way that addresses the root problem of dopamine imbalance in the brain. CAM treatment options include Synaptamine, a “medical food” and other nutritional supplements directed at increasing dopamine levels in the brain areas associated with RDS.
All recommendations advised at Accurate Clinic regarding these alternative approaches to the management of addiction are safe and based on sound evidence-based research. For further investigation of the research upon which the recommendations here are based, see the “References” section at the bottom of each education page.
(see CAM – Addiction Recovery).
Behavioral Management of Opioid SUD
Addressing triggers to addictive behavior and preventing relapse includes the management of chronic pain, sleep adequacy, stress management, anxiety and depression as well as maintenance of general physical well-being, at Accurate Clinic we work with our patients to address these concerns.
In addition to the above, other behavioral interventions are emphasized including Cognitive Behavior Training (CBT) and “mindful exercises” such as meditation, yoga, and hypnosis/self-hypnosis training.
Due to time limitations associated with individual appointments with our physician, we encourage our patients to explore our website to discover the other services and educational resources that we offer that facilitate relapse prevention (see “Services” and “Education” links in the menu bar at the top of each web page).
Medical Management of Opioid SUD
Medical management of opioid SUD can be further broken down into medication-assisted treatment (MAT), including conventional prescription medications such as buprenorphine (Suboxone, Zubsolv, Bunavail and Probuphine), methadone and naltrexone. (see Buprenorphine).
Buprenorphine vs. Methadone
When comparing the use of buprenorphine vs. methadone in opioid SUD, there are a number of variables to consider but overall buprenorphine is probably the best choice for most people. The American Psychiatric Association recommends buprenorphine as the first drug of choice. With respect to the induction phase when patients are first started on buprenophine or methadone, recent studies show fewer deaths with buprenorphine. Less deaths were also associated with buprenorphine during treatment as well as over the first 12 months when treatment is discontinued. After 12 months of discontinued use, the death rates for buprenorphine and methadone are about the same.
Regarding treatment retention, the likelihood a patient will remain in treatment is better with methadone compared to buprenorphine when low doses (<40 mg/day methadone or < 7 mg/day buprenorphine) of each medication are used. However, when moderate or high doses of either medication are used, treatment retention is the same.
With respect to side effects, buprenorphine appears to be less sedating than methadone and “clarity of thinking” is also thought to be better with buprenorphine although it is difficult to confirm with studies. Early in the history of buprenorphine management it was believed that buprenorphine was responsible for liver toxicity in a small percentage of patients. Most recent research indicates that buprenorphine is not toxic to the liver.
During treatment, mortality rates are significantly better with buprenorphine vs methadone in almost every study in this country and Europe. Fatal overdoses with buprenorphine as the sole medication are rare and are mostly associated with unintended ingestions in children. On the other hand, unintentional drug-related deaths are highest with methadone compared with others (methadone (31%), hydrocodone (19%), alprazolam (15%), and oxycodone (15%).
Naltrexone is another viable option for long term medical maintenance to prevent relapse and does offer some advantages over buprenorphine and methadone. It can be implemented after initial management with either buprenorphine or methadone and offers a safer, though less effective option for long term use. There is a theoretical argument against use of long term naltrexone based on reward deficiency syndrome theory. Additional information regarding naltrexone will be uploaded in the near future.
Adjunctive Medical Management of Opioid SUD
In addition to buprenorphine, there are additional, adjunctive treatments available than can be helpful in reducing both opioid withdrawal symptoms as well as reducing the cravings and drives to relapse.
NMDA Antagonists – Memantine (Namenda)
A recent 2015 study evaluated the use of memantine in conjunction with buprenorphine in young adults (average age 22 y/o) with opioid addiction. Patients were placed on a short 9-week course of buprenorphine as a detox regimen along with memantine 15mg/day or 30mg/day vs. placebo. In comparism with the 15mg/day or placebo treatment groups, memantine 30mg/day offered the following benefits:
(1) Craving for opioids was significant reduced.
(2) Opioid withdrawal symptoms were significantly reduced.
(3) Reduced early opioid use relapse after rapid buprenorphine discontinuation at week 9.
(4) No serious adverse events
Additional information regarding memantine will be uploaded in the near future.
5-HT3 antagonists – Ondansetron (Zofran)
Ondansetron, commonly used to treat nausea and vomiting, also has been shown to reduce other symptoms of opioid withdrawal.
Additional information regarding ondansetron will be uploaded in the near future.
Documents for First Visit (download all)
- Information Request Form (form 1428)
- Buprenorphine – Informed Consent (form 1519)
- Buprenorphine – Controlled Substances Agreement (form 1440)
- Buprenorphine Controlled Substances Agreement – Pregnancy (form 1652)
- Buprenorphine for Opioid Substance Use Disorder
Opiate Addiction Education
Addiction – Resources
- Alcoholics Anonymous: A.A. Near You
- Narcotics Anonymous: N.A. Near You
- SAMHSA Self-Help, Peer Support, and Consumer Groups
- National Institute on Alcohol Abuse and Alcoholism
- National Institute on Drug Abuse
- National Library of Medicine
- DrugFree.org – Resources
- Partnership for a Drug-Free America
- Substance Abuse and Mental Health Services Administration
Addiction – Starting Out: Treating Opioid Addiction
- What are the treatments for heroin addiction? – NIDA
- Facts about Buprenorphine for Treatment of Opioid Addiction
- Medication-Assisted Treatment for Opioid Addiction – Facts for Families and Friends
- Buprenorphine (for Opioid Substance Use Disorder)
Addiction – Understanding Why
Addiction – Understanding Relapse
- Imbalanced Decision Hierarchy in Addicts Emerging from Drug-Hijacked Dopamine Spiraling Circuit – 2013
Addiction – Pregnancy and Breast Feeding
- ABM Clinical Protocol #21- Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, Revised 2015
- Breastfeeding and Opiate Substitution Therapy – Starting to Understand Infant Feeding Choices – 2016
- Buprenorphine Treatment of Opioid-Dependent Pregnant Women – A Comprehensive Review – 2015
- Buprenorphine and norbuprenorphine concentrations in human breast milk samples determined by liquid chromatography-tandem mass spectrometry. 2005 – PubMed – NCBI
Addiction – Medical Management
Addiction – Buprenorphine vs. Methadone
- New developments in the management of opioid dependence – focus on sublingual buprenorphine–naloxone
Addiction – Naltrexone
Addiction – Adjuncts to Medical Management
Addiction Adjuncts – NMDA Antagonists: Memantine (Namenda)
Addiction Adjuncts – 5-HT3 antagonists: Ondansetron (Zofran)
Emphasis on Education
Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.
For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.
Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.
For more information, please contact Accurate Clinic.
Supplements recommended by Dr. Ehlenberger may be purchased commercially online or at Accurate Clinic.
Please read about our statement regarding the sale of products recommended by Dr. Ehlenberger.
Accurate Supplement Prices