1. New Patient Orientation
Welcome to the RCG Family!

2. Addiction or Dependence?
Is there a difference? Physical dependence to opioids means that the body relies on an external source of opioids to prevent withdrawal. Addiction is a condition(disease) manifesting as uncontrollable cravings, inability to stop using a drug despite adverse social, psychological, and/or physical consequences. It is also accompanied by the need for an increased amount of a substance as times goes on to achieve the same desired effect. Opioid addiction is accompanied by tolerance, physical dependence, and withdrawal syndrome.

3. The Anatomy of Addiction
The neuroanatomy of addiction and human subjects has documented metabolic changes noted on PET scan.
Addiction results in deeply ingrained memories capable of creating intense urges and patient exposure to triggers – emotional or sensory, after years of abstinence.

4. Biology of the Brain

5. Brain Activity-Addict
Biology of the Brain
Brain Activity-Non Addict
Brain Activity-Addict

6. The Addicted Brain

7. The Addicted Brain
Drug addiction is a disease of the brain associated with abnormal behavior. We continue using the drug, despite doing significant social, physical and psychological harm to ourselves.
Drugs of abuse provide longer and larger highs
5-10 times increases in dopamine to the brain than natural reinforcers as in food or sex.
Opioid Dependence is a Chronic Brain Disease shown to cause: 1
Pervasive changes in cognitive and drug-rewarding circuits 1
Significant altercations in the neurochemical, molecular and cellular levels 1
Changes to brain structure and function that persist long after the drug has ceased 1

8. The Addicted Brain in Recovery

9. Suboxone What is Suboxone? Buprenorphine
Combined buprenorphine and naloxone – sublingual film
Buprenorphine
Has been used since early 1980’s in the United States for pain control known as Buprenex at 0.4mg IM or SQ.
Has been approved in 2000 for use in the treatment of opioid/opiate addiction, dependence. It has also been used to convert Methadone maintenance patients to eventually get them off Methadone completely.
Is a partial mu agonist. It also has some unclear action at the opioid kappa receptor.
Is 25 times stronger than morphine. Analgesic does equivalence of buprenorphine to Morphine sulfate is 1/25. Meaning: 0.4mg buprenorphine will relieve pain equal to Morphine Sulfate 10mg.
Is partial agonist to the mu receptor, therefore, a ceiling effect. Meaning: if buprenorphine dose is increased to a certain point, there is NO increase in pain control or euphoric effect.
It is very long acting at the opioid mu receptor, up to 40 hours; usually about 28 hours in average. Meaning: less withdrawal when stopped taking.

10. Suboxone Buprenorphine
Has very strong affinity to the opioid mu receptor. Meaning: buprenorphine will displace other opioids/opiates from the mu receptor resulting in acute opioid withdrawal syndrome that will discourage addicts to use buprenorphine along with other opioid.
Also, from this strong opioid mu receptor affinity, buprenorphine will prevent other opioids from having any affect at all, therefore, discouraging using other opioids since the addict will not feel any effect of their drugs.
In case of emergency, when pain control is really needed, higher dose of full opioid mu agonist can be used to achieve adequate pain control.
There is clear federal guidelines for using buprenorphine in the detoxification and outpatient maintenance treatment for opioid and opiate addiction.

11. Opioid Agonist vs Antagonist

12. Opioid Receptor in the brain
Buprenorphine
Opioid
Empty Receptor
Withdrawal Pain
Opioid Receptor in the brain
Courtesy of NAABT, Inc. (naabt.org)
Opioid receptor unsatisfied -- Withdrawal. As someone becomes “tolerant” to opioids their opioid receptors become less sensitive. More opioids are then required to produce the same effect. Once “physically dependent” the body can no longer manufacture enough natural opioids to keep up with this increased demand. Whenever there is an insufficient amount of opioid receptors activated, the body feels pain. This is withdrawal.

13. Perfect Fit - Maximum Opioid Effect
Empty Receptor
Euphoric Opioid Effect
No Withdrawal Pain
Courtesy of NAABT, Inc. (naabt.org)
Opioid receptor satisfied with a full-agonist opioid. The strong opioid effect of heroin and painkillers stops the withdrawal for a period of time (4-24 hours). Initially, euphoric effects can be felt. However, after prolonged use, tolerance and physical dependence can develop. Now, instead of producing a euphoric effect, the opioids are primarily just preventing withdrawal symptoms.

14. Imperfect Fit – Limited Euphoric Opioid Effect
Courtesy of NAABT, Inc. (naabt.org)
Opioids replaced and blocked by buprenorphine. Buprenorphine competes with the full agonist opioids for the receptor. Since buprenorphine has a higher affinity (stronger binding ability) it expels existing opioids and blocks others from attaching. As a partial agonist, the buprenorphine has a limited opioid effect, enough to stop withdrawal but not enough to cause intense euphoria.

15. Buprenorphine Still Blocks Opioids as It Dissipates
Courtesy of NAABT, Inc. (naabt.org)
Over time (24-72 hours) buprenorphine dissipates, but still creates a limited opioid effect (enough to prevent withdrawal) and continues to block other opioids from attaching to the opioid receptors.

16. Perfect Fit - Maximum Opioid Effect
Empty Receptor
Euphoric Opioid Effect
No Withdrawal Pain
Opioid
Buprenorphine
Empty Receptor
Receptor Sends Pain Signal to the Brain
Withdrawal Pain
Imperfect Fit – Limited Euphoric Opioid Effect
Buprenorphine Still Blocks Opioids as It Dissipates
Courtesy of NAABT, Inc. (naabt.org)

17. Medication Assisted Treatment (M.A.T.)
Medication assisted treatment is the treatment of addiction with the assistance of medication (Suboxone, Vivitrol, methadone).
A multi-faceted approach is the best approach.
Individual counseling, group counseling, 12-step meetings, support groups, accountability partners, spiritual groups/support are all very important components of successful treatment.
A common mistake during M.A.T. is to rely solely on the medication without addressing the underlying behavioral and cognitive issues associated with addiction.
Many people in M.A.T. assume that because they feel better and their life is “back on track” they don’t need to do any thing other than take the medication.
Attack the addiction from as many directions as possible!

18. M.A.T.
As of now, or in the near future, there are five methods of Medication Assisted Treatment.
1) Overdose Prevention.(Narcan)
2) Vivitrol injection. (Vivitrol)
3) Buprenorphine implants. (Probuphine)
4) Injectable Buprenorphine.
5) Oral administration of Buprenorphine. (Suboxone)

19. M.A.T.- O/D Prevention
1) Injecting Naloxone (Narcan). Narcan immediately reverses the effects of opiates, often times saving the users life. It can be administered by a pre-loaded injectable, nasal spray or the Evzio device, which injects the medicine in the leg using a device much like an Epi-pen. Narcan is an opiate antagonist, which is stronger than the agonist(heroin), therefore it binds to the receptors much quicker, overriding any effects from the opitae.

20. M.A.T. -Vivitrol Injection
2) Vivitrol contains naloxone, which is an opiate antagonist. It is a long lasting dose that is injected intramuscularly once a month. This helps reduce cravings for opiates and also blocks opiates from binding to the receptors in the brain if taken. It was originally developed for alcoholism but was found to work well for opiate addiction.

21. M.A.T- Buprenorphine Implants
3) Probuphine. This is a delivery system that is implanted under the skin of the patients arm. The implant lasts for six months. This system cuts down on diversion and the possibility of a patient losing or forgetting to take their medicine.

22. M.A.T.-Injectable Buprenorphine
4) This is not yet on the market, but will be soon. It is a monthly injection, much like Vivitrol, but contains Buprenorphine, which is the active ingredient in Suboxone. It is a partial-opiate agonist.

23. M.A.T. -Oral Administration
5) Oral administration of Buprenorphine. This includes Suboxone, Zubsolv and Bunavail. These medicines all have buprenorphine and naltraxone. Subutex is also used in rare cases, which contains buprenorphine but not naltrexone.

24. Harmful Drugs (worldwide)

25. Treatment Plan
Create objectives(short term goals or methods which are measurable) that improve your chances for a successful treatment plan.
Examples:
Occupational goals
Relationship goals
Hobbies (stay busy)
Exercise (releases endorphines)
Debt cancellation
Buy/rent a house
Savings/ Checking account
Clean urine screens
Education goals ( Complete GED, Enroll/Re-enroll into College or Trade School)
Taper medication

26. Treatment Plan Create long term goals. Examples:
Get off of Suboxone or taper to sub-therapeutic dose
Career Goals
Financial Goals
Relationship/Family Goals
Long Term Educational Goals

27. Treatment Plan Change PPT (People, Places and Things) People Places
These may be long time friends, acquaintances or even family members that jeopardize the success of our recovery.
Sometimes it may be extremely difficult to distance ourselves from these people.
Places
This may be a town, an area, residence, room or vehicle that you frequented or identified with during your active addiction.
Things
This could be a certain song, stress, item, time of day, or routine that identifies with using your drug of choice.

28. Treatment Plan-Preventing Relapse
Triggers: These can be any number of things involving people, places and things. Everyone has their own triggers.
The Behavior Chain
Triggers-Thinking-Feeling-Behavior-Consequence
Example: Bob drives past a house where he bought dope in the past.(This is the trigger). Bob thinks “man, this week has been crazy, I’d love to get high.”(The trigger initiates thinking.) Bob craves a shot of heroin. (The thinking initiates a feeling.) Bob turns into the house and buys a bag of dope. (The feeling initiates behavior.) Bob relapses. (The behavior has a consequence,)
Treatment, including counseling and meetings will teach you coping mechanisms to deal with these triggers.
Life happens! We are still going to have good days, bad days and stressors that we have to deal with. We must learn to deal with these events on OUR terms, not with drugs.

29. Drugs are no longer an option for me!
Preventing Relapse
Suboxone will take care of the physical need for opiates, but it will not prevent you from giving in to triggers or change existing behaviors. Determine what people, places and things make you vulnerable to relapse. Stay away from these triggers as much as possible.
DO NOT let the trigger initiate old behavior. STOP and THINK. The following are some common INACCURATE thoughts.
It is not going to hurt.
No one is going to know.
I need to relax.
I’ll just do it once.
I have had a rough day, week, or month.
My friends want me to get high with them.
I never had a problem with weed, so it’s not really relapsing.
It’s the only way I can sleep.
I can do whatever I want
I am lonely.
Drugs are no longer an option for me!

30. Relapse Prevention
There are several ways to help yourself prevent relapsing.
Develop a daily relapse prevention plan(ask your counselor for assistance with this).
Have a strong social support system
Have an accountability partner
Parent or spouse
Sponsor
Physician
Counselor
Spiritual guide
Make a list of 10 reasons why you want to stay clean. Never forget those reasons. Read the list over and over to yourself.
Develop coping skills (again, ask your counselor if you need assistance).

31. Treatment Plan
The following page is a list of resources you can use to help you defeat your addiction. Use as many “weapons” as possible. Go to war with your addiction. You can do this. You will do this. Follow the advice of your Dr.’s, counselors and staff and you will be successful.

32. Resources for Recovery
Websites
(Forums, tips, self-help guides. Secular group)
(find a meeting)
(find a meeting)
(Christian based recovery program. Local meetings.)
(Government resources)
(Forums, tips, etc…)
(Excellent resources)
(Videos, forums, blogs, stories, support groups)
(motivational, information)
(support groups, tips, advice)
(on line meetings)
(on line meeting)
(tips, guides, etc…)
(Zubsolv’s home page)
(Suboxone’s home page)
(Bunavail’s home page)
(articles)
D.A.W.N-Drug Abuse Warning Network
There are specific forums for people taking Buprenorphine products

33. Resources for Recovery
Smartphone Apps
InReach (Apple only)
NA Self Help (Apple and Android)
NA meeting finder (Apple and Android)
BetterHelp (Apple and Android)
No More! (Apple and Android)
Recovery Today (Apple and Android)
Recovery Box (Apple)
Squirrel Recovery; Addiction (Android)
Addicaid-Addict Support (Android)
New2Recovery for Addictions (Android)
Drug Addiction (Android)
*There are numerous apps for recovering addicts and more are created everyday. There are support groups, blogs, forums, meetings, tips, advice, clean-time clocks, etc… Just check the App Store that applies to your smartphone.

34. Books and Publications
The Big Book of Alcoholics Anonymous
The Big Book of Narcotics Annonymous
The Life Recovery Workbook: A Biblical Guide Through the Twelve Steps
Dreamland- The True Tale of America’s Opiate Epidemic-Sam Quinones
Why Can’t Jjohnny Just Quit? Kyle Oh, M.D.
SMART Recovery Handbook
Clean: Overcoming Addiction and Ending America’s Greatest Tragedy- David Sheff
Codependent No More: How to Stop Controlling Others and Start Caring for Yourself- Melody Beattle
Healing the Shame That Binds You- John Bradshaw
How To Stop Time: Heroin From A to Z -Ann Marlowe
Jagged Little Edges: Life After Addiction- Lorelie Rozzano (several books in this series)
Dope- Sara Gran
We All Fall Down: Living With Addiction – Nic Sheff
Pill Head: The Secret Life of a Painkiller Addict – Joshua Lyon
Opiate Addiction-The Painkiller Addiction Epidemic, Heroin Addiction and the Way Out- Taite Adams
**There are Thousands of books and memoirs on drug addiction and recovery. These are a few of the popular and best-ranked books on the subject.

35. Local Organizations Alcoholics Anonymous- www.aa.org
Local meetings with over 58,000 locations in the USA
Narcotics Anonymous-
Local meetings held daily with several locations.
SMART Recovery-
Secular organization which accepts MAT(Suboxone) as a viable type of recovery. They are primarily a web-based community, but there are actual meetings in and around central Ohio.
Celebrate Recovery-
Spiritual, church based program with several locations throughout Ohio and the USA.
Al-Anon-
Al-anon and Alateen are both sub groups based off of the AA principles. These are primarily for families and teens dealing with addiction in their famiy.

36. You Can Do This! One Day at a Time
Always remind yourself that you’re an addict and always in a battle
Stay active in your recovery
Be selfish about your recovery(no one can do it but you)
In the words of the great comedian George Carlin…”just because you got the MONKEY off your back doesn’t mean the circus has left town.”
Good luck in your recovery!