Accurate Education – Addiction Recovery

Addiction

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:
 

 

Opioid Addiction Criteria:

1. Continuing to use opioids despite negative personal consequences from their use
2. Repeatedly unable to carry out major obligations at work, school, or home due to opioid use
3. Recurrent inappropriate use of opioids in physically hazardous situations
4. Continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use
5. Tolerance as defined by a need for markedly increased amounts to achieve intoxication or get high
6. Using greater amounts of opioids or using over a longer time period than intended
7. Persistent desire to use opioids and/or unsuccessful efforts to cut down or control opioid use
8. Spending a lot of time obtaining, using, or recovering from the effects of using opioids
9. Stopping or reducing important social, occupational, or recreational activities in order to use to opioids
10. Persistent use of opioids despite acknowledgment of persistent or recurrent physical or psychological problems that are a result of using opioids
11. Craving or a strong desire to use opioids

 

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:

“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:

“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.

What is the basis, or root cause, of addiction?

 

Reward Deficiency Syndrome (RDS)

Associated with this new definition and understanding of addiction is a major paradigm shift in our  approaches to treatment.

See: Reward Deficiency Syndrome (RDS)

 

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 diet,  Synaptamine, a “medical food” and other nutritional supplements directed at increasing dopamine levels in the brain areas associated with RDS.

See Dopamine Diet

 

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 by providing training in Cognitive Behavior Therapy (CBT), “mindful exercises” such as meditation and yoga, and self-hypnosis techniques.

See CBT, Hypnosis and Meditation and”Mindful Exercises”.

 

 

Pain Management

Recognizing that many people with opioid SUD also suffer from chronic pain, at Accurate Clinic we offer extensive non-opioid pain management options. We recognize that inadequate pain control is a significant trigger to relapse and therefore pain must be addressed effectively.

 

 

Other Services

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

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.

See Opioid Withdrawal

 

 

Downloads

 

Accurate’s Buprenorphine-Based Opioid Addiction Recovery Program

Documents for First Visit (download all)

1. Information Request Form (form 1428)
2. Buprenorphine – Informed Consent (form 1519)
3. Buprenorphine – Controlled Substances Agreement (form 1440)
4. Buprenorphine Controlled Substances Agreement – Pregnancy (form 1652)
5. Buprenorphine for Opioid Substance Use Disorder

References:

Opiate Addiction Education

1. ASAM Definition of Addiction 

 

Addiction – Resources

1. Alcoholics Anonymous: A.A. Near You
2. Narcotics Anonymous: N.A. Near You
3. SAMHSA Self-Help, Peer Support, and Consumer Groups
4. National Institute on Alcohol Abuse and Alcoholism
5. National Institute on Drug Abuse
6. National Library of Medicine
7. DrugFree.org – Resources
8. Partnership for a Drug-Free America
9. Substance Abuse and Mental Health Services Administration
10. Smart Recovery.org

 

Addiction – Starting Out: Treating Opioid Addiction

1. What are the treatments for heroin addiction? – NIDA
2. Facts about Buprenorphine for Treatment of Opioid Addiction
3. Medication-Assisted Treatment for Opioid Addiction – Facts for Families and Friends
4. Buprenorphine (for Opioid Substance Use Disorder)
5. Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse – 2018
6. Buprenorphine and Naloxone Combinations and Dopamine – 2018
7. Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220 PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse – 2018
8. Insurance Companies Fighting the Peer Review Empire without any Validity – the Case for Addiction and Pain Modalities in the face of an American Drug Epidemic – 2018
9. Promoting Precision Addiction Management (PAM) to Combat the Global Opioid Crisis – 2018
10. The Benefits of Genetic Addiction Risk Score (GARS™) Testing in Substance Use Disorder (SUD) – 2018
11. Genetic addiction risk score (GARS) ™, a predictor of vulnerability to opioid dependence. – PubMed – NCBI
12. Hypothesizing That Brain Reward Circuitry Genes Are Genetic Antecedents of Pain Sensitivity and Critical Diagnostic and Pharmacogenomic Treatment Targets for Chronic Pain Conditions – 2009 
13. Does Naltrexone Affect Craving in Abstinent Opioid-Dependent Patients? – 2007
14. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X-BOT) – a multicentre, open-label, randomised controlled trial – 2018

 

Addiction – Understanding Why

1. Understanding the High Mind – Humans Are Still Evolving Genetically – 2011
2. Genetic addiction risk score (GARS) ™, a predictor of vulnerability to opioid dependence. – PubMed – NCBI
3. Promoting Precision Addiction Management (PAM) to Combat the Global Opioid Crisis – 2018
4. The Benefits of Genetic Addiction Risk Score (GARS™) Testing in Substance Use Disorder (SUD) – 2018
5. Hypothesizing That Brain Reward Circuitry Genes Are Genetic Antecedents of Pain Sensitivity and Critical Diagnostic and Pharmacogenomic Treatment Targets for Chronic Pain Conditions – 2009
6. Insurance Companies Fighting the Peer Review Empire without any Validity – the Case for Addiction and Pain Modalities in the face of an American Drug Epidemic – 2018
7. Addiction through Three Different Perspectives – 2016

 

Addiction – Understanding Relapse

1. Imbalanced Decision Hierarchy in Addicts Emerging from Drug-Hijacked Dopamine Spiraling Circuit – 2013

 

Addiction – Understanding Risks: Chronic Traumatic Encephalopathy

Resources:

1. Chronic Traumatic Encephalopathy (CTE)/ Symptoms, Causes, Prevention (WebMD)
2. NAD Therapy – San Diego CA
3. NAD Therapy – Springfield Wellness Center – Springfield LA
   

 

References:

 

1. White matter integrity and cognition in chronic traumatic brain injury: a diffusion tensor imaging study. – PubMed – NCBI – 2007
2. Chronic Traumatic Encephalopathy in Athletes – Progressive Tauopathy following Repetitive Head Injury – 2010
3. Chronic traumatic encephalopathy (CTE)
4. Chronic Traumatic Encephalopathy in Professional American Football Players – Where Are We Now? – 2018
5. The Biological Basis of Chronic Traumatic Encephalopathy following Blast Injury – A Literature Review – 2017
6. Current Understanding of Chronic Traumatic Encephalopathy – 2014
7. Salsalate treatment following traumatic brain injury reduces inflammation and promotes a neuroprotective and neurogenic transcriptional response with concomitant functional recovery – 2017
8. Role of Tau Acetylation in Alzheimer’s Disease and Chronic Traumatic Encephalopathy – The Way Forward for Successful Treatment – 2017
9. Does neuroinflammation drive the relationship between tau hyperphosphorylation and dementia development following traumatic brain injury? – PubMed – NCBI
10. Endocannabinoids and traumatic brain injury – 2011
11. Endocannabinoids – A Promising Impact for Traumatic Brain Injury. – 2017
12. Mast Cell Activation in Brain Injury, Stress, and Post-traumatic Stress Disorder and Alzheimer’s Disease Pathogenesis – 2017
13. The Inflammatory Continuum of Traumatic Brain Injury and Alzheimer’s Disease – 2018
14. Does neuroinflammation drive the relationship between tau hyperphosphorylation and dementia development following traumatic brain injury? – PubMed – NCBI
15. Preventive Effects of Resveratrol on Endocannabinoid System and Synaptic Protein Modifications in Rat Cerebral Cortex Challenged by Bilateral Common Carotid Artery Occlusion and Reperfusion – 2018
16. Natural cannabinoids improve dopamine neurotransmission and tau and amyloid pathology in a mouse model of tauopathy. – PubMed – NCBI

 

Addiction – Pregnancy and Breast Feeding

1. ABM Clinical Protocol #21- Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, Revised 2015
2. Breastfeeding and Opiate Substitution Therapy – Starting to Understand Infant Feeding Choices – 2016
3. Buprenorphine Treatment of Opioid-Dependent Pregnant Women – A Comprehensive Review – 2015
4. Buprenorphine and norbuprenorphine concentrations in human breast milk samples determined by liquid chromatography-tandem mass spectrometry. 2005 – PubMed – NCBI

 

Addiction – Treating Pain

1. Use of conventional, complementary, and alternative treatments for pain among individuals seeking primary care treatment with buprenorphine-naloxone – 2012 
2. Characterizing Pain and Associated Coping Strategies in Methadone and Buprenorphine Maintained Patients – 2015

Addiction Management – Counseling & Groups

 12 Step Recovery Programs

Narcotics Anonymous

1. Narcotics Anonymous: N.A. Near You

 

 Alternatives to 12 Step Recovery Programs

Overview

1. The Irrationality of Alcoholics Anonymous

Smart Recovery

1. Introduction to SMART Recovery®

 

Addiction Management – Medication

Addiction – Buprenorphine vs. Methadone

See: Buprenorphine for Opioid SUD

1. New developments in the management of opioid dependence – focus on sublingual buprenorphine–naloxone

 

Addiction – Naltrexone

1. clinical-use-of-extended-release-injectable-naltrexone-in-the-of-opiod-use-disorders-a-brief-guide-SAMHSA
2. baseline-characteristics-of-patients-predicting-suitability-for-rapid-naltrexone-induction-2015
3. opioid-detoxification-and-naltrexone-induction-strategies-recommendations-for-clinical-practice-2012
4. a-placebo-controlled-trial-of-memantine-as-an-adjunct-to-injectable-extendedrelease-naltrexone-for-opioid-dependence-2014
5. cost-effectiveness-of-injectable-extended-release-naltrexone-compared-to-methadone-maintenance-and-buprenorphine-maintenance-treatment-for-opioid-dependence-2015
6. injectable-extended-release-naltrexone-for-opioid-dependence-2011
7. buprenorphine-mediated-transition-from-opioid-agonist-to-antagonist-treatment-2012

 

Addiction – Mechanisms of Addiction

Neurobiology of Addiction

1. The Nucleus Accumbens – Mechanisms of Addiction across Drug Classes Reflect the Importance of Glutamate Homeostasis – 2016

 
 

Addiction – Adjunctive Medication Management

Adjunctive Medications – NMDA Antagonists: Memantine (Namenda)

1. memantine-improves-buprenorphinenaloxone-treatment-for-opioid-dependent-young-adults-2015
2. memantine-produces-modest-reductions-in-heroin-induced-subjective-responses-in-human-research-volunteers-pubmed-ncbi
3. a-placebo-controlled-trial-of-memantine-as-an-adjunct-to-injectable-extended release-naltrexone-for-opioid-dependence-2014

 
Adjunctive Medications – 5-HT3 antagonists: Ondansetron (Zofran)

1. ondansetron-an-effective-treatment-for-the-withdrawal-symptoms-of-opioids
2. From mouse to man – the 5-HT3 receptor modulates physical dependence on opioid narcotics – 2009
3. Ondansetron Pharmacokinetics in Pregnant Women and Neonates – Towards a New Treatment for Neonatal Abstinence Syndrome – 2015
4. 5-Hydroxytryptamine Type 3 Receptor Modulates Opioid-induced Hyperalgesia and Tolerance in Mice – 2011
5. ondansetron-a-review-of-its-pharmacology-and-preliminary-clinical-findings-in-novel-applications-pubmed-ncbi
6. prevention-of-morphine-discontinuation-phenomenon-in-mice-by-ondansetron-a-selective-5-ht3-antagonist-pubmed-ncbi
7. prevention-by-the-5-ht3-receptor-antagonist-ondansetron-of-morphine-dependence-and-tolerance-in-the-rat-1996
8. the-5-ht3b-subunit-affects-high-potency-inhibition-of-5-ht3-receptors-by-morphine-2012
9. agonist-and-antagonist-induced-up-regulation-of-surface-5-ht3a-receptors-2015

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

 
 
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