everything you need to know about medications like Suboxone, methadone and Vivitrol for opioid addiction treatment, with Lauren Hoffman, Ph.D.
Host: Brenda Zane, brenda@brendazane.com
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Show Resources:
Recovery Research Institute website
Lauren Hoffman, Ph.D. email
Pharmacotherapy article - treating opioid use disorder with medication - includes a table of medications and information about each
SAMHSA Buprenorphine treatment locator tool
SAMHSA: MAT Medications, Counseling, and Related Conditions
Show Transcript:
Speaker: Brenda Zane, Dr. Lauren Hoffman
Brenda 02:39
Hello, welcome to an episode that I am hoping will answer a lot of questions that you might have around medication for treating opioid use disorder. This is a hot topic that can be really confusing for people. And I had a lot of questions that I wanted to get answered around using medication to treat opioid addiction when you're talking about adolescence specifically, and this information is not easy to find. So I spent a lot of time and tracked down with Dr. Lauren Hoffman, who is a postdoctoral research fellow at Massachusetts General Hospital and Harvard Medical School. Dr. Hoffman also works with The Recovery Research Institute where she studies substance use disorder, their treatments and how people can find a successful recovery. She has a Ph.D. in psychology.
And her focus is around the study of alcohol and drugs both licit and illicit, and how they affect the central nervous system and human behavior. She has expertise in neurophysiological techniques, and neuropsychological testing as it relates to addiction psychology. And can I just say that I have some ridiculously smart people on Hopestream. So I get a little nervous going into these conversations because obviously, people like Dr. Hoffman are just off the charts brilliant when it comes to this stuff. But I have to say she was so great to speak with so down to earth made me feel really comfortable, and I think you'll really get a lot out of what she shares. It was hugely informative. And because this topic is pretty deep, we went a little long, but trust me, it is worth listening to the end. So if you've got a long drive or if your dog needs some extra exercise today, this will be the perfect episode for you. And be sure to check out the show notes because we talk a lot about specific drugs and specific information that you might have an interest in diving deeper into so you'll find all of that in the show notes. So let's get to it. Please enjoy. Now this conversation I had with with Dr. Lauren Hoffman with recovery Research Institute.
Brenda 05:01
Welcome, Dr. Lauren Hoffman to Hopestream. I'm thrilled to have you here today and get your expertise on all things, medication and opioid use disorder. So thank you for making the time and joining me
Dr. Hoffman 05:15
Of course, thank you for having me, excited to be here.
Brenda 05:18
I'm excited too! There's so much confusion about this topic in particular. So I'm glad to have you with us to sort of, I think, clear up maybe some misperceptions that are out there. And also just give some good information. Because it's really hard sometimes to find, especially if you have a kid who's struggling, and you're, you know, on Google at two o'clock in the morning,
Dr. Hoffman 05:44
oh, exactly, like, how can I access and find this information?
Brenda 05:47
Right? And who do I trust, right? Like who? Oh, yeah, who do I trust with his information? Because sometimes you'll be reading something that is so wacky, and then you look like, what website am I on?
Dr. Hoffman 05:57
There's a lot of predatory information out there, too. You know, making sure that you're picking the right treatment program or going down the right path can be difficult.
Brenda 06:07
Yes, totally. Well, before we do that, I'd love to ask my guests just a question to let people get to know you personally a little bit better. And that is, what did you want to be when you were growing up?
Dr. Hoffman 06:19
Oh, that's a great question. Interestingly enough, probably when I was very young, I wanted to be a veterinarian, just because of my love for animals. And it probably crossed over to I ultimately decided I didn't want to do that, because I love animals too much. And you have to see animals were sick. That is the other side of the job. Yeah, so I always, always, though, had an interest in addiction and the brain and psychology. And so, you know, I think I found the right place in the end.
Brenda 06:58
Yes, definitely. Well, the human race definitely won out on that one that you work with us versus animals. I can see that, going into the veterinarian world, thinking how fun and then when you realize, oh, but they're all sick. So how did you sort of come to be doing what you're doing today, because I can imagine it's an interesting path that you followed, but maybe you can give us just sort of a quick snapshot of how you came to be doing what you're doing.
Dr. Hoffman 07:31
You know, all substance use disorders are of interest to me. But my current work is largely focused on opioid use disorder. And my interest in opioid use disorder was originally founded in my youth, as an adolescent, after direct experience with specifically my mother suffering from substance use disorder, opioid use disorder specifically. So I really wanted to find a way to help folks.
I saw how long it took my mom to get to a place where she was listened to where she wasn't being forced into a particular program that didn't meet her needs, and then returning back to that program over and over, and, I still tell her things and she says, I've never heard others say this before, things like, recovery is for life. And it's about maintaining and sustaining it and you still need that support and can get that support. And, and so I think that my interest and desire to help people is really what drives my career focus, specifically, around opioid use disorder just because I've seen how it affected my life and my mother's life. And now is affecting, you know, the entire world. Right?
Brenda 08:50
So, so much. And I'm just curious, with your mom, did you know what was going on? Because of being so young? If you were, you know, in your early teens, that had been really confusing. Did you understand what was happening back then?
Dr. Hoffman 09:07
I definitely did, but I think it's likely more so because I was the oldest sibling so I have one younger sister. At that point in time, my, my parents had been divorced for quite some time. And then my stepfather and my mother got divorced at around when I was 13. And that's really when it came down to it's my turn to take care of things or my turn to solve the problem, if you will. And, and so I think it was, you know, I don't really have all the answers, but I can manage this for now. Yeah, so I think I, I knew more. What was and I think this is true for a lot of adolescents, right. They know a lot more than and we probably give them credit for
Brenda 09:55
absolutely
Dr. Hoffman 09:56
it's you know, adapting to the situation. But I say all the time, I'm so grateful to have gone through that experience and would not change it for anything because it got me to where I am today. And, you know, there's no animosity, there's no, you know, negative emotions towards it, I really am grateful that I was able to learn so much at a young age and most kids that age, if you ask them don't really understand opioid use disorder might have, you know, some stigma around it. So I feel grateful
Brenda 10:28
what a gift for your mom to have you, especially now being so educated in this field, to not have that blame, because I could imagine if you didn't really understand opioid use disorder, or substance use or any substance use disorder, that it would be very easy to blame your parents. Because I'm sure life had to have been a pretty chaotic place if your mom is, is struggling with that.
Dr. Hoffman 10:54
Yeah, I mean, not just that, but the stigma and the discrimination that goes along with it. And she still struggles with that, like self-stigma and, and a lot of the discrimination that she's experienced and continues to experience and just general, you know, medical health care in her life. And it's nice, that I can be that voice to remind her, you don't have to be so hard on yourself, you know, you're doing a great job. You know, there's a lot of over the years of going to a lot of different treatment centers and clinics and trying different treatments. Back in the day, there wasn't as much emphasis on being aware of stigma and making sure that we're supporting folks and treating this for what it is, a medical condition.
Brenda 11:40
Really, I'm excited to talk with you about medication that is being used to treat specifically opioid use disorder. Because, you know, the listeners of this podcast are mainly parents of young people, I would say is 13, up to around, you know, mid-20s or so. And they're all in various stages of either experimentation or addiction or trying to live in recovery. It's surprising to me that I'll still have people ask me, they kind of whispered Is it okay to use Suboxone? You know, like it's this horrible thing. So maybe you could just give us sort of the 101, first of all, just coming from a place of somebody who doesn't know anything about medications that can be used for this kind of what are they and what do they treat?
Dr. Hoffman 12:33
I know this from the United States perspective, most so I'm going to focus on that. But
Brenda 12:37
yeah, that's a good point.
Dr. Hoffman 12:40
But in the US, so there are three FDA-approved medications. The first is methadone. The second is buprenorphine. And the third is extended-release injectable naltrexone, which is also referred to as Vivitrol. You may have heard buprenorphine referred to as Suboxone or Subutex. I do want to note that buprenorphine and methadone, are shown to be generally equally as equally effective as one another when they're given the right doses. So it's not like one is better than the other. It's just what's right for the individual.
Dr. Hoffman 13:14
And Vivitrol is, or naltrexone is also used to treat alcohol use disorder. But there's one other medication that I do think is important to know, before we go into some of the details around those medications. And that's that Naloxone is a medication that's not used to treat opioid use disorder, but it is used to reverse an opioid overdose. And it's something that I think everyone should have access to. And everyone should go grab a Naloxone kit, if they can. It's I mean, it's I carry it around in my bag, all of my interns have had their Naloxone in their backpacks or their bags. Keeping more than one kit on hand is usually a good idea because it might take more than one dose to ensure reversing the overdose, but anyone can access them. A lot of states have standing orders that don't require a prescription, you can walk in and grab it at any pharmacy. So not necessarily used to treat but definitely save saves lives.
Brenda 14:12
Absolutely. Thank you for mentioning that. That's super important. I mean, my son is alive only because of Narcan, which is the brand name for one of the brand names for Naloxone, but yes,
Dr. Hoffman 14:23
yes. So that's the term I should have used. I apologize.
Brenda 14:27
I know all these names get confusing. And I will put in the show notes a little like directory of the names, you know of the drugs and what they do so that if you're listening, don't worry about writing these all down. I'll put those in the show notes. So you have them.
Dr. Hoffman 14:42
Yeah, so I mean in terms of these three medications, they are somewhat different. So extended-release injectable naltrexone, which are referred to you know, on and off interchangeably as that or Vivitrol, which is the brand name and it's it's generally administered about every four weeks via injection, there's no recommended length of treatment necessarily with it. And they used to give oral naltrexone. But we know now that that's not as effective and it's now no longer recommended because compliance with taking the medication every day was was somewhat low.
And then there's buprenorphine are also known as Suboxone or Subutex. And these are recommended for people who, so you should not initiate it until they're, you know, overt signs of opioid withdrawal. And that's because if you give buprenorphine to someone they can, you can precipitate withdrawal, if they have used opioids, too close to when or illicit opioids too close to when buprenorphine is administered. But typically, once you get to a place where you're experiencing significant enough withdrawals, they'll start you want to dose about two to four milligrams and then increase it in increments of two to eight until you're about at about eight to 16 milligrams is pretty standard doses above 24 milligrams per day are really not shown to be more effective than lower doses that are about you know, 16 milligrams, 80 milligrams, so forth.
Dr. Hoffman 16:16
And there are several other formulations for it also. So you may have heard of Sublocade, and Sublocade is a weekly or monthly injection for buprenorphine. And then there's also Probuphine, and that's an implant that goes under the skin and provides a constant low-level dose of buprenorphine. So there are different formulations of it. And again, there's no real recommended time for buprenorphine treatment, the length of time, some folks are on it, you know, long term, some folks might even use it for the majority of their lives. But there is a recommendation researcher recommendations, because we know that, you know, recent data has come out, and suggests that if individuals are receiving buprenorphine or methadone, for less than six months, they experience more overdose events, more serious opioid-related acute care episodes. So ensuring that you're on the treatment for long enough. And some folks might even suggest you know that the lower limit is a year of medication treatment.
But being aware of the fact that, you know, you shouldn't discontinue it too quickly, is pretty important. And then there's methadone. And so methadone is a little more heavily monitored. So it requires daily clinic visits to get your dose. Whereas buprenorphine, usually you start with some take-homes, and maybe it's a prescription of you know, three tablets or sublingual films because it can also be dissolved under the tongue. Whereas with methadone, you'll get your dose at the clinic, and then have to return the next day to get a dose as well. And you may eventually get take-homes, but that's usually reserved for folks who've been on the clinic for a while have been compliant. And so usually, folks started around, you know, 10 to 30 milligrams and then increase to about 60 to 120 is kind of the average goal. But it really varies from person to person. And there are specific regulations around adult adolescence. I'm not sure if you wanted me to talk about those.
Brenda 18:27
Yeah, well, I think it's, it's good just to sort of get a lay of the land of what's out there. I think a lot of times parents if they do know anything about these medications, is they worry about diversion still, right? If you've got them to Suboxone pills, are they, you know, is my kid gonna go out and sell them? So I think it's really great to know that there are options to that, like you said, with the implant. So I think that's just great base information. And then yeah, it can be hard when we have younger kids. And I think at least I felt this way that might, you know, my kid's gonna pull out of this, like this is going to correct in the next three to six months or six months to a year. He doesn't need to be on medication, you know, there's just part of it might be denial.
But I think also part of it is just sort of lack of information about, you know, for these younger kids. And for some reasons, 17 seems to be the age when you know, I have this community of moms and it seems like the kids really tend to go get to sort of dive deep into trouble at 17. Not that they haven't before, because they definitely do. But that seems just to be this age. And so if you could just talk about kind of whether this is safe for kids, is it recommended? And you could probably talk about what the youngest age would be recommended, but that is a concern. So I would love to get your thoughts on that.
Dr. Hoffman 19:58
In terms of you know, no recommendations and age related things. So there's, there are a few things that I would point out is so for example, the American Society of Addiction Medicine, they define adolescence as ages 11 to 21. So pretty broad range all the ranges of early development. And they have recently updated all of their guidelines in 2020. And they are now suggesting that clinicians should consider treating adolescents who have opioid use disorder using the full range of options. So that includes agonist and antagonist medications for naltrexone, or extended-release naltrexone that's been approved by the FDA for patient patients 18 and older. For buprenorphine, you have it approved for patients 16 and older when it's given in the context of an opioid treatment program. And then it's when it's prescribed through a buprenorphine waivered physician, like a primary care physician, I don't believe there are as strict of age limits around that. And methadone is approved for patients aged 18 and older.
But that does not mean that all clinicians follow these FDA approvals, and it's a lot of off-label treatment. So you can provide buprenorphine and methadone to patients under 18 via opioid treatment programs if they have a documented history of at least two prior unsuccessful withdrawal management or treatment attempts. And if written consent is typically if written consent is given by a parent or legal guardian. Okay.
Brenda 21:29
That's great to know. Really good to know. Yeah.
Dr. Hoffman 21:33
Yeah. And then I would also probably say that the literature is mostly geared towards adults. And so there are a few studies that are have looked at or demonstrated the efficacy of extended-release injectable naltrexone, and adolescents and young adults. And there are really no major safety risks, risks that we think we would see, but there hasn't really been a safety trial necessarily. However, we know, we know folks are using this and they're doing fine.
Brenda 22:13
Oh, yeah. Well, like you said, I have had parents say, oh, you know, I'm worried about that. And I just am astounded. I'm like, so they're taking fentanyl, which could kill them instantaneously today, and you're worried about 20 years down the row what the impact of some buprenorphine might have I mean, it's so illogical.
Dr. Hoffman 22:35
I know. I know, it doesn't make sense. But I mean, I imagine many of those folks probably just aren't educated enough to understand that it's not the same exact thing. It's completely different. And it's effective. Like I know that for methadone there really are no controlled trials in adults younger than 18. But there are descriptive studies that support the usefulness of buprenorphine, and there have been randomized controlled trials for buprenorphine. Now, the average age of that a lot of them were over the age of 18. But there was this subset of folks who were in these younger age groups, and you still see better retention and treatment, more negative urine drug screens for opioids and greater initiation of aftercare treatment with other medications like naltrexone. And then you also see less opioid use, less injection drug use, less treatment outside of the context of what's provided, and the medication centers are not seeking like emergency department visits and other acute care, and better retention and treatment.
So it's there all of these things that can benefit. It's not just you know, it's hard to define recovery. So we think, well, what are the benefits? And how does it help but you know, it spans a large area, so you can keep you in retention it can or sorry to keep you in treatment and keep you engaged and keep you from using from misusing opioids. And that's all great. and prevent overdose, of course.
Brenda 24:06
Exactly. That's the thing. And like you said, it doesn't have to be for a lifetime. I think that's also a concern for some people
Dr. Hoffman 24:15
especially among adolescents and young adults, I would say, my personal opinion, just as my person would, I would say, you know, for older for middle-aged and older adults, I always say, yeah, a lot of these individuals are on these medications throughout their life and do very well on them. And there aren't complications, but I think the idea for an adolescent or a young adult is can we get them to a place where they can have normalcy in their life and lead a prosperous life and can we give them that opportunity where I would say probably the goal would be to ultimately get them off the medication just that several years on medication, right? So yeah, right.
Brenda 24:57
yeah, I mean, adolescence is just so kind of hard for everyone, even without substance use issues. So yes, getting somebody through those really tough years and maybe through college when there's a lot of environmental and peer pressure, and then maybe that's something that they walk away from, but there is a perception like, Oh, my kids 16 or 17, you know, I don't want to be on this, this medication for the rest of their life. So, yeah, it's good to remember.
Dr. Hoffman 25:33
I mean, you had mentioned something before, I think it was the idea of natural recovery. And often we see probably parents are getting the idea of that from what we see with teens and alcohol and college and alcohol. And we know that often, you know, it's socially acceptable, and that picks up and then it dies down a little after college. And most people tend not to develop a problem, but some a certain percentage do. But with opioid use disorder, it's like you very rarely hear about people using fentanyl, recreationally. Right. It's just that's not the way it works.
Brenda 26:15
Would you mind actually going back, you had mentioned agonist and antagonist and I think that's something that's really confusing for a lot of people. So I'm wondering if you could just give us a quick rundown on what those are what they mean.
Dr. Hoffman 26:29
Yeah, no problem. So antagonists, you can think of antagonists as medications that block the receptor. So they don't allow or they occupy the receptor and block illicit opioids from binding to it. So they're blocking the effect of an illicit opioid when used and when I say receptor, I mean, receptors that we all have different receptors in the brain, you may have heard of a mu-opioid receptor, that's the common, that's where the illicit opioids and opioids tend to exert their effects primarily.
And an agonist will stimulate that receptor, almost kind of mimicking, I don't want to say mimicking, necessarily, because it's completely different from the effects that that normal opioids have. So if someone were to take bike it in, they would have an immediate effect. And it would, it would, it would definitely have, you know, you would get a sensation of pleasure, enjoyment, right, all the things we think when we when we associate with illicit opioid use. But, these agonists actually work at a slower pace. So they're going to occupy the receptor longer, they're going to be in your system longer, and they're going to act more slowly over time. So the effect is not a peak effect that are exerted. And then you see the, you know, associated, quote, high, you don't see that with these agonist medications. So there is a distinction. So even though it's activating it, it's a little bit.
Brenda 28:04
Okay. That's, that's good to know. Because I think that can be a bit confusing. So that antagonist totally occupies that. So if opioids come knocking, it's already fought, like there's it's not getting in. Versus the Yeah, is that accurate? Or how would you?
Dr. Hoffman 28:22
Yeah, there are some instances where if you take a large enough amount of an illicit opioid, you can trigger, you know, you can knock the medication off the receptor. And there are concerns around that with like, fentanyl, for example, because it has a really strong affinity or, in other words, a strong attack attraction to the receptors. And so, there are concerns there, and this actually surprised me, I didn't know that for quite a while. And I'm like, Oh, I know, a whole lot about opioids and the brain.
Brenda 28:59
If you're surprised, I don't know
Dr. Hoffman 29:02
why it makes it makes a lot of sense, but it's just not talked about a lot. And, and with fentanyl, and, you know, a lot of the heroin is gone. I mean, at least on the East Coast, it's all fentanyl essentially. So much more dangerous.
Brenda 29:18
Yeah, absolutely. Okay, that's good to know. And then the agonist, as you're saying, it does stimulate it, but in a different way than the illicit ones are going to.
Dr. Hoffman 29:31
Yes. So it's, it will stimulate it, but in a way that is, it's like taking an extended-release version of a medication kind of its, you know, I would kind of compare it to that where you're not going to get this immediate effect. There's not this wanting or need for it necessarily.
Brenda 29:50
Okay, perfect. And then, so going back now we'll just go back to the ages, the American Society of Addiction Medicine, that is so you said that they are recommending these medications to be used for younger age groups, I think is where we left off.
Dr. Hoffman 30:08
Yes. So they were saying for adolescents 11 to 21. They're suggesting that clinicians consider these medication treatments along with the full range of other treatment options. And although psychosocial treatment is recommended, if possible for adolescence, it's certainly not required. And that means that it really should be determined on an individual needs assessment basis, not everyone is going to benefit from psychosocial treatment. And their this comes from a lot of studies showing that psychosocial treatment doesn't necessarily have a significant benefit above and beyond medication alone, at least in adults. And so it may be more warranted for like more complex cases, for those with comorbidities more severe substance use disorders. But for adolescence, they recommend a little more probably, probably going to benefit a little more probably recommended, if possible, but we know not everyone has that.
Brenda 31:06
So when you say psychosocial, you're meaning like a group therapy type or what does that constitute?
Dr. Hoffman 31:13
Good questions. So psycho-social, yes. So like cognitive behavioral therapy, or motivational interviewing or motivational enhancement therapies? And so there are tons of different essentially behavioral therapies that are out there.
Brenda 31:30
Well, yeah, and I was talking about this with somebody the other day that I think with the challenge with adolescents sometimes is that they if they don't have a peer group, who is also, you know, sober or not using substances or supportive of them, which often they're not, right, these kids are within a group of people who are like, yo, like, that's, you know, what are you doing come back, and so they don't have a group that's cheering them on saying, good job, like, great and helping them.
Whereas maybe an adult who's trying to, you know, get off of opioids, they might have a whole family and a peer group at work, or wherever that's really cheering them on and rooting them on. Whereas these kids, a lot of times, if they have to stay in the same school in the same environment, they're just getting sucked right back into the same negativity in the same group of people who are giving them substances and alcohol and all that. So I could see where even if they were using medication, just to have some social support could be really important.
Dr. Hoffman 32:38
Yes, yes. And that's one thing that I wanted to make sure we got to today actually was talking about, you know, utilization of recovery support services, and, and how important they are. For folks, opioid use disorder and substance use disorders in general, are chronic medical conditions is how we think about them today. And that means just like losing weight, you don't just take a magic pill and lose a bunch of weight, and then you're, you're gonna look like that forever, right? It's, it's about maintaining and being engaged and continuing to be motivated.
And so to maintain recovery, medication is a starting point, it's this point to get a person to a place where they can actually benefit from other services, they can benefit and, and absorb the information that's given to them that they can then use to apply to their own situation. And so if you take away, you know, the uncomfortable withdrawal symptoms and the craving, you reduce the craving, someone can focus on the recovery pathway. But if you take the medication away, and there's nothing else there just to support an individual, there's going to be a problem, because now there's nothing else for them to fall back on to support their recovery.
And so I know that I know that some have said, you know, probably for adolescents, that there shouldn't be group counseling might be detrimental in with adolescence only because there can be, you know, one person in the group or two people in the group who then encourage each other to continue to use substances. But I really do think it's important to have that peer relationship at some point, or in some context within the treatment and recovery path.
Brenda 34:27
I think you're right, because when you were talking about that, that time period between going into withdrawal, and how are you going to make it through that and if you know, a lot of times kids can't get into treatment programs for whatever reason, maybe it's financial, maybe it's COVID. Maybe it's the 50,000 other reasons why we have a really hard time getting our kids into treatment. So if you can bridge that and let them get rid of that anxiety and all the physical drawl symptoms, then, it seems like all of a sudden, maybe you can start thinking about other things. Like, how do I, you know, find some good friends. But if you're going through that, you know what I mean, my son described it as just absolute hell, that detoxing period and the withdrawals there's just no way you're going to be thinking like, oh, maybe I should go find some positive friends, or maybe I should go get a job. That's just not gonna happen.
Dr. Hoffman 35:31
Yeah, I mean, it's almost like there needs to be an opportunity or a chance. And if we can't provide the opportunity to the patient, then then they're not going to be able to move forward whatsoever. And it's a constant cycle. And there are some, it's kind of difficult, right, because the medications that we have available, I do think it's important for folks to stay on them for a period of time enough that really, it's gonna vary, though, it's very individualized. It's, you know, what progress is this individual making and have they what achievements have they made over the course of their recovery, and do they have other supports and other abstinence, encouraging social circles, but that but also that are medication positive because of an individual's on a medication, there's a lot of undeserved stigma around it. And, and being aware of that is really important for making sure that your daughter or son is not being put into a situation where they're really being discriminated against, and so forth. And so finding the right program for them and knowing what their ideals are, and making sure that they meet the needs of the person who is seeking treatment is just as important.
Brenda 36:49
So I think what I'm hearing you say is if you do have a son or daughter, you get them on these medications. A, it could definitely be a game-changer for getting them through that period of just going through withdrawals. And, and, or maybe they have overdosed, and they're in the hospital, because this happens all the time. They've overdosed, they're in the hospital, you might have a brief moment where they're a little bit more willing to consider options. It might not be a big window, but it might be a little window, and maybe you can step in at that time, and then that you don't need to be embarrassed that your child is on this. They don't need to be embarrassed by it. Even though there is some stigma out there. It's just one of those things. I don't know. Like if you have to take insulin for diabetes, is that embarrassing? Right, exactly. So that's great to hear fromthe medical profession, that this is not something that is looked down on like, Oh, you know, this person's taking methadone or, and I think methadone is got its own set of stigmatizing things around it. Absolutely. But in general, the medication is not looked at from your standpoint, or from the medical professional standpoint, as this bad thing, it's actually a good thing.
Dr. Hoffman 38:13
It depends...a modern clinician or psychologist who is up to date on the research will know that medication is the most is proven to be the most effective treatment for opioid use disorder. And there are some folks you might go to or a primary care physician, you might not even know and you might ask them about medication, and they'll just flat out say those are bad for you. Those are not good for you. You don't want to be on those for a long period of time or take someone off of medication too soon. And it can be so detrimental. Like it's just not suggested to use these medications just for withdrawal. While in detox or to manage withdrawal. It's really to maintain and it's about saving lives, right. It's about preventing overdose and making sure that the person I mean, just spending 5,10, even 20 days in detox is not going to get you to a point where you've you've been treated and you're going to come out fully recovered. And that's the way it is.
Brenda 39:12
Right, that's a fantasy. And also I've had talked to parents who've sent their kids off to a program and the program discontinues their medication and they did not know this going into it. So I think that's a good reminder, if you are looking for placement for your child, ask about their policy so that you don't have that because Can you imagine if they were taking Suboxone for 30 days or 15 days or whatever and doing really well and then they get to treatment and they stop it.
Dr. Hoffman 39:45
It's infuriating. I've seen far too many barriers and hindrances. I'm like, can't we just make this easy for people? I mean, they're having a hard enough time. Why does the system in some sort of way or what program have to have to make it that much more difficult for them. But that's why I mean, it's so important to advocate for your loved ones and make sure that you're helping them make the right decisions and getting them the program that best meets their needs. Because there are a ton of programs out there. And so it's really just about doing your homework and your research and finding, you know, asking questions and being that annoying person who calls like, I know, I would do it. They might hate me. But I all know at the end that I found the right place.
Brenda 40:31
So if you are looking for a doctor for this, so you would be looking for a psychiatrist or what do you look for? Like how, how would you actually start looking for a person who could help you with this?
Dr. Hoffman 40:45
There are, it depends on the medication. So naltrexone is generally administered by anyone who's licensed to prescribe medication. So that could be your primary care provider, physician assistant, a nurse practitioner, and it's really just asking if they have it or can offer it, and usually they can. Buprenorphine can be prescribed by anyone with a waiver to prescribe it. So you need a waiver in order to prescribe buprenorphine. And these folks who can administer are typically physicians, nurse practitioners, physician assistants, clinical nurse specialists, and so forth. And it can also be prescribed by a SAMHSA accredited opioid treatment program. So SAMHSA is the Substance Abuse and Mental Health Services Administration, and it's the overseeing government agency that determines opiate treatment standards and accreditation. And so methadone is obviously more highly regulated. And by law, it can only be administered in a SAMHSA certified treatment program or an opioid treatment program, which is why we typically hear of methadone clinics and less so hear of a buprenorphine clinic.
Brenda 42:01
Okay. Yeah, and I will in the show notes, I'll put a link, SAMHSA's got a great directory.
Dr. Hoffman 42:08
Yes, I was just going to say that
Brenda 42:11
That's probably the easiest way. I mean, you could call your family doctor, your general practitioner, but if you're really seriously looking for somebody who can administer these, they've got a great directory put together and so we'll link out to that.
Dr. Hoffman 42:26
Yeah, and there's also a hotline, a referral hotline as well.
Brenda 42:29
Perfect, So I'll give you a little scenario here, maybe you can, we can talk through it. If you've got a 17 year old, you know, they're, you know, they're drinking alcohol, they're smoking marijuana, those are sort of the givens, then you're pretty sure they're taking some oxy, which is probably oxy with fentanyl in it with they're probably taking some Xanax, this is kind of the most common scenario that I see. They've been doing that for six months, maybe a year, they're getting into lots of trouble, they're not going to school they have they're not going to therapy at home, you know, there's lots of anger, and it's just chaos. Is that how, how would a parent with a kid like that start thinking about is medication, something that we should think about? Or do I just try to get them shipped off to a wilderness therapy program? You know, how does a family or even a therapist or doctor know, okay, this is the right time when maybe a medication would be a good addition to what we're trying?
Dr. Hoffman 43:36
Right. And I know that my response might be somewhat controversial.
Brenda 43:42
That's ok, I like controversy. I'm fine with that.
Dr. Hoffman 43:47
But I think I think it's a misconception that everyone should be seeking behavioral therapy. And if that doesn't work, then we should seek medication. Because that is opening an opportunity for the disorder to worsen for potential overdose and related fatality. And I think really, the time to get on medication and to engage in medication treatment is probably at the forefront. Now, of course, there needs to be an evaluation, there needs to be an assessment of how what's the severity? Is this individual currently taking substances or have they been abstinent for maybe a week or two? What's their living environment like? what's their readiness for change? What are their emotional, behavioral or cognitive conditions?
And these are all things that need to be considered when considering what's the right path for someone you know, a good doctor will know that medication is probably superior to detox or therapy or rehab and given alone and that does didn't mean that medication necessarily that everyone would necessarily do well with medication alone. And it should really be a comprehensive treatment program. So involving recovery support services, like mutual help groups or organizations, various other extracurricular activities that don't better, you know, accidents based or substance free.
And ultimately, it's really an individualized approach. So I would say if I wanted to make a blanket statement, don't be afraid of medication. And I think that if you're worried, and if the use I mean, we know opioid use disorder is one of relative to other substances, there's this telescoping effect with it. So what that means is, is people will transition from first use to regular use to problem use, and then to treatment much more quickly than you see with alcohol, for example. Yeah, and so it's like the severity ramps up pretty quickly. And if there's injection drug use, you might have you know, there's risk for infectious disease, and really intervening prior before it gets too severe. Can potentially save someone's life.
And I think it's also important to consider is the individual with the opioid use disorder? What do they want? What are their thoughts? Do they have ideas that are pro or con medication? And if that's the case, can we educate them on the benefits, or the pros and cons that actually exist, and then re-evaluate and reassess what they're thinking if they're not ready for medication? I'm thinking just off the past, I don't know that there's any research to actually back this. But I'm thinking, you know, if somebody is not sure if there's always the opportunity, so let's say somebody can't stop using illicit opioids, perhaps a controlled environment, like inpatient for 30 days, and a treatment program that offers Vivitrol might be appropriate for that individual.
And I say that because medications typically are talked about when people don't want to go on them. It's usually, but I don't want another opioid in my body. And so Vivitrol is not an antagonist, right, it blocks opioids. And so that could be an appropriate step. Because if you're going on Vivitrol, you have to have a lengthy period of abstinence prior to and that can be really difficult, it's very hard to get on Vivitrol. But if you have a controlled environment like that, if you're able to provide someone with a medically supervised withdrawal, where you can give them medications like methadone, or buprenorphine facilitated withdrawal, where you lower the dose slowly over time at detox, and then transition. So there's no one path that would fit all right. And so it's really individualized.
Brenda 48:11
That's really interesting. I'd never thought about that of thinking about introducing medication earlier. But yeah, there, there's that, that tipping point where the before they're, you know, injecting heroin, if you could maybe intervene then especially, because once you're there, I feel like that, that you've just stepped into a whole new world. So that is really interesting. Thought about sequencing that. And it's so important to ask them because I know in talking to my son just in sort of like the crowd that he was hanging around, it was like, Oh, I'm not going to go on Suboxone. I'm just gonna get addicted to that. And there is this big anti-Suboxone thing, now, it was probably really anti leaving my lifestyle, which he loved a lot. But he, you know, his perception was that a lot of people just found themselves Oh, well, now I'm just addicted to Suboxone. Is that a thing? Or how do you think about that?
Dr. Hoffman 49:16
I think that we hear that a lot from individuals who don't want to go on the medication right?
Brenda 49:21
That's what I was thinking too.
Dr. Hoffman 49:22
And it's not perfect. You know, some of these medications are hard to get on to some, some folks might take their buprenorphine too soon and actually cause the, you know, serious withdrawal symptoms. Starting naltrexone you have to be abstinent for a pretty long period of time. And then if you decide to go off a bit or off of any of these medications, really, there's a risk of overdose mortality, thereafter, heightened overdose mortality. So it's making sure that the medication gets a chance. So right education, education, education, right?
But a recent study came out looking at how people decided to start agonist treatment. And the most common explanation from those who from those patients was, Oh, well, I spoke to someone who had experience with this. And it really worked for them. Like they just it really works for them. It worked for them. And so now I have faith in it and want to try it. And I think that talking to someone who's in recovery and who's had that experience can be a huge game-changer. And there are stories I believe, maybe I just saw them the other day, maybe SAMHSA website of others in recovery, how they achieved their recovery. And we often don't hear these stories because of the stigma associated with medication. But if we heard more of them, I imagine more people would go, okay. I think I understand this a little better.
Brenda 50:58
And working with a doctor, because I do know, and I hear about it all the time. Oh, my kid, you know, just was in the hospital because some guy on the street had Suboxone. And he had a moment where he was like, okay, I'm gonna do this. And they just take whatever they get on the street. And what I'm hearing is, that is a really bad idea. Because you have to be, you have to time it right. You have to have the right dose. Like that just sounds like a disaster.
Dr. Hoffman 51:25
Yeah, well, I think most folks use illicit or street Suboxone for the purposes of easing withdrawal when they can't access other medications. And so there are some studies showing that that is the primary reason and so even though there's a lot of concern around diversion for buprenorphine, especially when someone isn't taking their medication, so that I do believe is a very serious concern. But I would say in terms of like obtaining it, there aren't many people going out and seeking these medications. However, I tend to deal with those who are mostly, you know, moderate or severe opioid use disorder. And so perhaps someone could start with Suboxone. But I, I tend not to think of it as something where if somebody was, you know, using heroin or fentanyl, Suboxone is definitely not going to provide them the same kind of effect. So it would probably just mitigate or hold them over for a while until they were able to access their drug of choice.
Brenda 52:26
you mentioned there's sort of that tapering off, can somebody go from active addiction to using Suboxone maybe to get through a really horrible withdrawal and detox period, and then can they taper off that completely to then get to Vivitrol? Is there a path like that? Or do you kind of just pick one and go for it?
Dr. Hoffman 52:52
No, no, of course, you can always get off of these medications, you can transition across these medications or two different behavioral therapies throughout. So there's no particular clear defined path, there is a way I would say, don't jump the gun and switch immediately. But of course, like the best doctor is going to go is this working for you? And they're gonna keep asking you that question every time you come to see them, because ultimately, it might not and something might change, and then there may need to be a transition.
Now, of course, transitioning from buprenorphine, and Naloxone would require a taper, and buprenorphine is tapered very slowly, typically, so it happens, you know, maybe over several months. So understanding that at the forefront, can help a patient, you know, not be so distressed when they realize oh, it's gonna take me months to get off this, well, you know, like two months, maybe you can go down more quickly. It just depends on your dose and how much you're prepared to feel discomfort by lowering the dose.
And so you can transition pretty easily. I mean, really, pretty easily from buprenorphine and methadone, and from methadone to buprenorphine, and then transitioning those to Vivitrol. It's a little more nuanced, but it's 100% possible, especially if somebody has been on a medication for a, you know, a year they're doing very well they decide, you know, I really am not using any substances anymore. I just want to make sure I have something on board to protect me in the future. If I find myself in that situation, and in that case, transitioning to Vivitrol might be appropriate, depending on the person's level of stability at that time.
Brenda 54:35
So if somebody is on Vivitrol, and they let's say they have a setback and they use, they get an oxy 30 and they use it, will they feel anything or what's what's actually going on when that happens?
Dr. Hoffman 54:49
Yes, the Vivitrol will block the illicit drug from binding to the receptor. So you won't get an effect again, you know, with really, really high doses of fentanyl. I've read a couple things about it displacing the Vivitrol medication from from the receptor in the brain. And so you might be able to get a little bit, you know, but it's very masked by the medication.
Brenda 55:17
And would the same thing be true for alcohol?
Dr. Hoffman 55:20
So with alcohol, it's blocking it. Now, I don't know exactly how it works pharmacologically with alcohol. I do know that it blocks the effects, but my level of knowledge around Vivitrol and alcohol is very limited.
Brenda 55:33
I know that's okay. It just popped into my head. I thought, well, wait a minute, if it's blocking that is it blocking other things, too?
Dr. Hoffman 55:39
Yeah. So opioids, I think it's just a little more complicated.
Brenda 55:43
Oh true. Yeah,
Dr. Hoffman 55:44
that would be scientifically, there are opioid second messenger systems. And then you have, you know, you have alcohol, you have the various neurotransmitter systems involved.
Brenda 55:55
that's a whole other realm that we would have to go into but, but amazing, amazing information, I'm trying to think of I get asked so many questions about this. I'm trying to think if there's anything, is there anything that you think that I have left out? Or that I should ask, knowing that there are parents listening, there could even be some young people listening who are interested in learning more about this too, and we were talking about the bottom lines before, which we'll get we'll get to as well. What do you most want to say to parents in particular, who have a kid who's struggling, and they're, they're really just desperate for resources and options.
Dr. Hoffman 56:36
I would say, first and foremost, find a physician, clinician, psychologist, or a treatment program that you can trust, someone that you know is going to be open to all of the paths to recovery, because any two paths do not look the same. And making sure that you find a program that's going to advocate for your daughter, son, that is going to advocate for you. And support everyone, is a system and understand that it's not just the medication, it's not, the counselor calls once a week and says how you doing, you're doing great, alright, good. You know, it's, it's more than that.
And I would also say, I know that a lot of people are against medication, and you're probably going to very much disagree with me and say, why would you give someone you know, why would you give a 15 or 16-year-old buprenorphine and, you know, their brain is still developing. And I think it's important to weigh the pros and cons. So my argument is, if my child were utilizing, or if my child was using heroin, or fentanyl, or was injecting substances intravenously, or had risky behaviors that could ultimately result in overdose, then it's far better to get that individual on a medication and save their life than to allow them to ultimately, potentially not make it. And not only that, but if you don't introduce the medication, because you're worried about oh, well, it might interfere with cognitive development. Well, certainly, you know, injection drug use with heroin and fentanyl...
Brenda 58:28
I think yes. I think that's probably a non-issue.
Dr. Hoffman 58:35
But I mean, it's just so obvious to me, and I'm thinking, why are so many people against it, then. And, you know, it isn't for everyone, and I understand a lot of people, medication is not for everyone, and I don't think it will be appropriate for everyone, but we know that it works. We know it saves lives, we know that it will give you have the opportunity to to succeed. And so it's kind of like if we know that works, why not. And then I'd also suggest looking into, you know, just educate yourself, go on SAMHSA's website, go on the NIH or National Institute on Drug Abuse website and see what's there, educate yourself and when you know more, then you'll know who you can trust and who you can't trust.
I would also mention recovery support services but completely forgot to mention there are things like recovery, high schools, and college recovery programs that are specifically designed for adolescents and young adults at those stages, to be surrounded by other folks who are also seeking recovery. And so these are other there are lots of recovery services, educating yourself on those things as well and all the things that are out there and available.
And I'd advise everyone to go on them on our website. So where I work is the Recovery Research Institute within Massachusetts General Hospital and Harvard Medical School. And we have our website is called recoveryanswers.org. And you can sign up for our monthly recovery bulletin there, which will give you all of the latest most up-to-date research, kind of synthesized and disseminated in a way that's really digestible and readable for the general public. We really enjoy writing those we really, they're very informative. So I'd advise everyone to do that as well. I think, you know, educating yourself is, is that first step.
Brenda 1:00:33
Absolutely. Oh, my gosh, the information on your site is so good and so helpful. And I will put that also in the show notes, links to get the newsletter, but also just to the website. And yes, if you're a parent, and you have questions about this, the information there is just phenomenal. Research-based, this is not Instagram people. This is real deal research. I'm always amazed when people say, well, I saw this thing on Instagram. And I'm like, no, no, it is not where you get your research and your recovery information.
Dr. Hoffman 1:01:10
I mean, it's hard to find it. There's so much out there. And there's so much misinformation. And if someone has a political stance on something, they will often make things up in order to support or back that statement. And, you know, I just I would hope that everyone gets a chance to be educated and make their own informed decisions.
Brenda 1:01:32
Definitely. What are you working on that you're excited about right now? We've had kind of a negative past year, so is there anything that's positive that you're working on that you want to share?
Dr. Hoffman 1:01:45
So currently, I'm doing a NIDA-funded study. So National Institutes on Drug Abuse. For this study, I'm looking at neuropsychological change, meaning cognitive change. So that's things like attention working memory, decision making, and how that changes over time. And patients who are starting medication treatment for opioid use disorder. And the relationship between those changes and recovery outcomes, like opioid use and quality of life, with the overall idea that if you want to help support recovery, you have to help support cognition, because we use our brain for everything. So if I'm sitting across from a counselor, or my psychologist, and they're giving me all this great information about how to support my recovery, but I am having attentional issues or memory issues, or I can't, you know, my decision-making skills are off as a result of, you know, using illicit opioids for a long period of time, then we need to give the brain a chance to recover and it does recover. It's just trying to figure out how long it takes and how can we support it. So if we can help improve cognition at the beginning of treatment? I, you know, my theory is we might be able to also facilitate somebody getting on the path to long-term sustained recovery, as well, right.
Brenda 1:03:08
Very cool. When will that be done?
Dr. Hoffman 1:03:11
We still have one more year in the project, maybe even two, we're lucky and get an extension. I mean, I'm really hopeful that this will yield some useful information. And yeah, we're doing some other projects, looking at recovery support services, and evaluating, you know, just all the paths to recovery that people go down. So lots of work. So keep an eye out on the recoveryanswers.com website.
Brenda 1:03:36
Definitely. And also, I think that's great to hear. What I love is that you probably see a lot of people in recovery. And that's just something that doesn't get talked about a lot, which is one reason why I do what I do, because my son recovered. And if somebody would have told me when he was in the thick of it, I would have said never in a million years. So I'm sure that you have really seen a lot of amazing things happen with people. And I think that's just good to continue to tell people because it does happen. I know when you're in the middle of it, it seems like it would never will. But it really really can.
Dr. Hoffman 1:04:15
My favorite part of what I do is working is the people, the patients talking to them, like I can be 100% me when I'm speaking to a patient, I don't know why. It's always been something that is very easy for me. But it's like the best feeling to connect to someone to know that they understand and that that you're there to listen and not judge and that you're someone who thinks well yeah, you can't get into recovery. And by the way, we know that people use substances when they're starting out on medication treatment, and that's normal. And I'm not going to judge you for that and I don't think that that's failure at all. Which it isn't, that's normal - some people's recovery paths involve that. And it's just about really connecting with these individuals and letting them know recovery is possible because it is possible. It's very possible.
Brenda 1:05:10
Well, and you have your mom to look at too.
Dr. Hoffman 1:05:14
Yeah, exactly. I mean, of course, its a roller coaster ride, their ups and their downs and things change over time, or, for example, being taken off certain medications, we went through that, too, she was on methadone for quite some time doing very, very well with it. And, you know, one doctor one day decided, nope, we're gonna take you off of this. So it's almost like staying vigilant. And understanding that there are a lot of people out there who don't understand, and who will not understand or who don't want to. And that's okay, you know, that's not my job to make them understand. But it is important to be aware of that and to know when to say, alright, you know what, maybe I don't agree with this doctor, and I want a second opinion, maybe I want to hear from a third doctor and make sure that that line of thought is right. And it's okay to do that, I would encourage everyone to get as many as much advice as they need.
Brenda 1:06:17
Right. And that's also where doing your research really pays off. Because if you have done your research, and then you're talking with a doctor or a program, and they say, well, we don't do that we don't use medication, we don't believe in it, at least you've got some knowledge in your head to either agree or disagree with that, as a parent, when you're looking for treatment for your kid, or you're looking for resources and help. You're so vulnerable because, you know, you might be a lawyer, or you might be a teacher or a bus driver, or whatever you're not an expert in addiction and addiction treatment. So you tend to really be vulnerable and believe what people are telling you.
So if you hear from a program, oh, well, we would never use that we, you know, our kids are never on on medications. If you haven't armed yourself with information, you're just gonna say, oh, okay, you know, and so being able to absorb the information that you're getting from all these different programs and read through it, and be able to have an opinion about it, or, you know, get on the phone and start calling people and asking them why don't you, where's your research that shows that we shouldn't? I just think as you said, you have to advocate you have to be informed because this is a life and death thing. I mean, there's just no two ways about it. This is a life-and-death thing. If your kid is using, you know, any kind of straight drug, it will have fentanyl in it. 100% guaranteed. And that is Russian roulette.
So I think spending some time reading and sometimes it's dense reading, I know for myself, you know, read some of this stuff, but you guys do a really good job in distilling things down. So if you're looking, if you're looking for understandable information, definitely, you know, go to www.recoveryanswers.org. And then just keep asking questions, like you said, call two doctors, or three doctors or four doctors if you need to. And don't be intimidated. Also, I think, you know, don't be intimidated by somebody telling you what their school of thought is.
Dr. Hoffman 1:08:29
Absolutely. And I would say for anyone who's experiencing or going through something like this, and really just feels stress, but also shame for feeling stressed about their own well-being, I would encourage you to know that you are 100% allowed to feel that way. And just as I did when I was younger, right, a different scenario, but making sure that you're taking care of yourself, otherwise you won't be able to help those around you that you love.
Brenda 1:08:59
Yeah, absolutely. I wish I could just tattoo that on my forehead, I pretty much tell everybody. Oh, my goodness, this is so amazing. Thank you so much for spending the time. And I know a lot of this is just elementary for you. But it's really helpful for us to hear somebody from a highly educated standpoint, be able to tell us this. And I just thank you so much.
Dr. Hoffman 1:09:24
Yeah, and you know, if anyone has any questions, you're welcome to also list my email address or potentially to reach out to the Recovery Research Institute.
Brenda 1:09:35
Wonderful, I'll do that in the show notes. So I'll put as much of this information, all the stuff that we talked about, and then I will have you if there's any particular articles or research that you think is great for parents. I will list that as well. And we'll get that out there for folks. So thank you and have a great, great rest of your day.
Dr. Hoffman 1:09:57
Thank you, you too. Thanks for having me.
Brenda 1:00:28
Thanks so much for listening, also, if you want to get on my email list, so you can get the email every Wednesday that I send out just as a way to support you and what you're going through you can go to Brendazane.com/email and just drop your email there and I'll send you a short kind of one-pager email on Wednesdays, and I would love to be able to do that for you.
You might also want to download my free ebook called “HINDSIGHT, Three Things I Wish I Knew When My Son Was Addicted To Drugs.” It is packed with information that I truly wish I had known back in the darker years with my son. And so I share it now in case it might be helpful to you in your journey. You can get that at Brendazane.com/hindsight, and I will put a link to both of these resources in the show notes as well.