In his St. Louis clinic, psychiatrist Dr. Arturo Taca sees many well-heeled patients trying to detox from heroin: doctors, lawyers, nurses. “Normal people with normal values getting addicted to heroin,” he says.
One thing they all have in common is that they have to fight the pain that comes with the symptoms of withdrawal from opioid addiction.
Brian Comer was one of those patients. In college, Comer was introduced to using prescription painkillers, like oxycodone or Vicodin, as party drugs. “It’s such an easy way in,” Comer says. “There’s no easy way out.”
After a year or so of abusing pills, Comer realized he had become dependent on them. When opioid dependence sets in, people can only feel normal when they maintain a certain level of the drug in their system. If they don’t keep taking the drug, they’ll experience withdrawal. For opioids, that includes tremors, anxiety, cramps, and diarrhea. These symptoms make it incredibly difficult for people to break the grip of opioid addiction.
Taca suspected that if he could make withdrawal easier and shorter for his patients, detox might be easier for them. The “aha” moment arrived when he was speaking to a friend, another doctor, who mentioned a small electronic device used to treat pain. If this device helps with pain, Taca thought, perhaps it can help patients manage the pain of detox. In his first tests with patients, he was amazed at the results. The device was able to alleviate most symptoms of withdrawal in 30 minutes. He called his friend back and said, “I think I just witnessed medical history.”
Comer was one of those patients. He had spent more than five years trying to ditch opioids to no avail. But with just one session with the device, called the Bridge, his withdrawal symptoms practically vanished. He’s been clean for more than a year since.
The Bridge looks like an oversized hearing aid festooned with wires. It releases a small electrical signal that targets the amygdala, a part of the brain that’s rich in opioid receptors and which regulates fear. The amygdala also has been shown to play a role in reward-seeking behavior, a key component of addiction. When opioid-dependent patients stop taking the drugs, their amygdalas becomes saturated with a stress-stimulating hormone.
During the dependency phase of addiction to prescription painkillers, the brain has to produce more and more noradrenaline to maintain normal levels of wakefulness. When those opioids are cut off, the same excessive levels of noradrenaline are pumped out for at least a week, which causes the symptoms of withdrawal. Taca says withdrawal is like the worst flu you’ve ever experienced, but worse. Along with feeling sick, people in withdrawal experience an intense fear or preoccupation with dying, he adds. “It’s harder for them to keep sober because they think they’re going to die.”
The Bridge device was released only two years ago, though similar devices have been on the market for the past decade. The FDA has approved the Bridge to be marketed and used in the same manner as similarly approved pain relief devices. For now, it is classified for use in “electro-acupuncture,” but Innovative Health Solutions, the Indiana-based medical device company that makes the Bridge, is in the process of applying for approval to use it in detox treatments, which would make it eligible for coverage under many people’s insurance plans. So far, the only peer-reviewed article to be published on use of the device in a detox setting was co-authored by Taca. It was a retrospective, uncontrolled study that looked at the results of people who had already received the treatment, not a pre-planned, double-blind study that is preferred by scientists when determining a treatment’s efficacy.
For many in that study, a one-hour session with the Bridge was enough to greatly reduce withdrawal symptoms. Within the first ten minutes of using the device, Comer says he could feel a difference. For one, he had stopped hyperventilating. “I was able to actually sit.” And within the first hour of wearing the Bridge, “I noticed almost no symptoms of any withdrawal,” he says.
That’s not to say the Bridge is a miracle device. Rather, it’s a start. What it does is open up some desperately-needed new options for breaking the cycle of addiction. After that, patients still have a long road to recovery.
During his dependency days, Comer eventually spent more than $100 a day on pain pills just to feel normal. His experience is fairly typical. Regular opioid users who still want to get a high have to take more and more of the drug. Many graduate to heroin or the dangerous painkiller fentanyl, a synthetic opioid that is 50 to 100 times more potent than morphine and has been driving an uptick in overdoses.
Fortunately for Comer, he never reached that level of addiction. After dropping out of school and losing his job, he moved home with his parents at age 23, determined to get clean. He started with an addiction treatment medication called Suboxone, which is a combination of buprenorphine and naloxone, a drug also known as Narcan that’s commonly used to reverse overdoses.
Withdrawal symptoms for treatment drugs can last even longer than those for addictive opioids.
Buprenorphine is one of only three medications approved to treat opioid addiction, the other two being methadone and naltrexone (also known by its brand name, Vivitrol). Naltrexone is the only one that isn’t an opioid. Both methadone and buprenorphine are themselves long-acting opioids, though they don’t deliver the high found in heroin or pain pills. In theory, these treatments, along with therapy, allow people to quit deadlier opioids and gradually wean themselves off drugs all together. But between 40–60% of patients relapse after treatment.
Comer was one of them. He could not quite shake his opioid dependence and ended up using Suboxone for four years, far longer than his time abusing painkillers. Though the Suboxone allowed Comer to feel more normal, every time he tried to wean off of it, withdrawal would upend his life. The problem was the treatment drugs—their withdrawal symptoms can last even longer than those for addictive opioids.
Comer, who has bipolar disorder, had already been seeing Taca, who offered a new option to kick the Suboxone. It wasn’t a simple process. Comer still would have to endure withdrawals for a week before visiting the clinic to use the Bridge for an hour. But the payoff, Taca promised, would be worth it: after that hour, the pain of withdrawal would be greatly diminished.
Comer’s story of opioid dependence is increasingly common. Nowadays, he more frequently hears about other people from his middle-class St. Louis suburb overdosing on heroin.
His experience—and that of his community—isn’t unusual. According to the Centers for Disease Control and Prevention, more than 15,000 people died from overdoses involving prescription opioids in 2015, quadruple the number from 1999. Two million Americans have abused or were dependent on prescription opioids in 2015.
Opioid addiction is often treated more as a moral failing than a health problem, and that appears to have skewed treatment options. Though the general consensus from the medical community is that medication-assisted therapy is more effective at keeping people off opioids than counseling alone, only a minority of treatment programs use it.
Only 13% of the more than 14,000 treatment facilities in the U.S. provided any of the medications approved for addiction treatment, according to a 2013 report by the U.S. Substance Abuse and Mental Health Services Administration. Methadone remains the most popular of the substitutes. Among patients at facilities offering medication-assisted treatment, some 330,000 received methadone. Only 48,000 received buprenorphine, and less than 4,000 were given naltrexone.
Taca uses the Bridge to transition addicts to naltrexone, which blocks opioid receptors, leaving people unable to experience the highs of the drug should they relapse. It’s available as a once-a month injection.
One of the reasons naltrexone is not commonly used is because its injectable form is relatively new, and it’s more expensive than methadone and buprenorphine. Another big hurdle is that patients can’t have opioids their system if they use it, so they have to detox first. That can be a daunting task.
Comer experienced “constant uneasiness” when he was going through detox. His body become highly sensitive. During one withdrawal process, he couldn’t sleep for days—no position felt comfortable. The pain and misery were so intense, he says, that it can feel like “there really is no end in sight.”
If you can get people on medications and into counseling, they seem to do better than with counseling alone.
The challenge of detox is why many patients choose to use methadone or buprenorphine even though their withdrawal symptoms can be worse than for the original opioids they were addicted to. Still, either can help someone kick heroin as quickly as possible, which could save their life.
With the Bridge, Taca hopes to take away the pain of withdrawal and make naltrexone a much more accessible treatment for addiction. And according to a recent study, naltrexone appears to be as effective as methadone and buprenorphine in keeping addicts from relapsing but doesn’t have the same risk of withdrawal.
Still, there hasn’t a been a comprehensive study comparing all three medications, but the consensus is that they’re better than the alternative of continued addiction to pain killers. If you can get a group of 100 people on any of these medications and into counseling, says Dr. Joshua Lee, an addiction researcher at New York University School of Medicine, they all seem to do better over time than people in counseling alone.
Lee tested naltrexone in a study among more than 300 parolees at five different sites. It was not a blinded study, so participants knew if they were getting naltrexone or just counseling. (The gold standard is a double-blind study, where neither patients nor doctors know who is getting which treatment.) The patients were seen every two weeks for a six month period. During that time, Lee and his colleagues found that those in the naltrexone group were much less likely to relapse. Approximately 60% had not relapsed at the six month mark, while about 60% in the counseling-only group had relapsed at that time.
But those positive results waned when doctors stopped administering naltrexone after six months. “Once the naltrexone was gone, then it resumed the usual trajectory of steady relapse,” Lee says. The researchers followed up with participants six months after halting naltrexone treatments and found that 50% of both groups tested positive for opioids. That suggested to him that six months might not be long enough.
Lee’s next study will tackle the question that many addiction researchers have—how do the three medications compare? He hopes to have results from that study by the end of the year.
Looking for Help
Ultimately, it seems that the best medication depends on a person’s circumstances. For those who have already detoxed—for instance, people getting out of jail—“your best option might be a shot of naltrexone the local sheriff is offering,” Lee says. One pilot program in Indiana, for instance, transitions parolees—most of whom have detoxed in jail—from the Bridge to naltrexone when they are released.
Making the treatments widely available solves only part of the problem, though. Even if patients can find a treatment facility or a program that offers medication, insurance companies may not pay for it. In Comer’s case, his insurance didn’t pay for naltrexone, so aside from one dose he was given for free, he went without.
It’s a challenge many patients face, from issues of access to lack of coverage to denied claims. “It is still really difficult to access behavioral health in general,” Lee adds. Seven years after the passage of the Affordable Care Act, two-thirds of plans violate at least one of the requirements for coverage of addiction treatments under the law, according to a recent report from the National Center on Addiction and Substance Abuse. “The most frequently excluded or not explicitly covered benefits were residential treatment and methadone maintenance therapy,” the authors wrote.
Nearly every state lags in offering enough medication-assisted treatments programs for their opioid dependent populations. Indiana is one of them. It has one of the highest rates of opioid abuse in the country while also having one of the lowest capacities for treatment. State Senator Jim Merritt says Indiana is just starting to address its treatments gaps. The state has some pilot programs that offer the Bridge to patients in detox, and Merritt has some 15 pieces of legislation in play that address a variety of opioid addiction treatment gaps.
“We need to continually talk about this being a struggle, this being about healthcare, not law enforcement,” Merritt says. “It’s an illness, not a character flaw.”
Comer echoes that sentiment, urging people who are addicted to opioids to ask for help. He had initially tried to hide his addiction from his family and friends. “I could have been done one or two years sooner if there wasn’t such a massive stigma.” But now, with the help of the Bridge and therapy sessions, he’s getting back on track. “There’s nothing now that’s holding me back from having a life.”
Photo credits: Kaje/Flickr (CC BY-NC) , Innovative Health Solutions