TREATMENT OPTIONS—OPIATE ABUSE
- Psychiatric Evaluation—Comprehensive written report written by Doctor, focus on current mental condition and underlying diagnosis. Credit given if a treatment services contract is signed within 10 business days.
- Treatment Evaluation—For Clients wishing to receive a written medical evaluation with treatment recommendation to share with personal physician or family members. Initial Intake, complete History & Physical with Medical Doctor, Biopsychosocial with Nurse, Psychiatric Evaluation by Doctor. No medications will be prescribed unless converted to treatment services contract. Credit given if a treatment services contract is signed within 10 business days.
- 3 Day Opioid Detox/Induction—Complete History & Physical, Blood work, Biopsychosocial, Psychiatric Evaluation, Doctor supervision of detoxification and induction to Suboxone or Subutex. For those patients who will receive their therapy outside Winter Park Recovery Center.
- 6 Month Opioid Maintenance with Individual Therapy—Complete History & Physical, Biopsychosocial, and Psychiatric Evaluation by Doctor. Six Medication Management Meetings with Doctor, monthly prescription service, two blood draws, random drug screens, up to twenty-four group therapy meetings and ASI tracking. Additionally, twelve individual therapy sessions.
- 12 Week Individual Opioid Therapy—Complete History & Physical, Biopsychosocial, and Psychiatric Evaluation by Doctor. Four Medication Management Meetings with Doctor includes prescription service, one blood draw, random drug screens, up to twelve group therapy meetings and ASI tracking. Additionally, Twelve individual therapy sessions. For those patients coming out of an inpatient facility, having no therapy componet documentation or needing an aftercare program. Does not include medications.
- 20 Week Individual Opioid Therapy—Complete History & Physical, two blood work/urine analysis, Psychiatric Evaluation, Doctor and Nurse supervision of detoxification and induction to Suboxone or Subutex. You will have 14 individual therapy appointments, one Spiritual Assessment, five Medical Management appointments, five Nurse appointments and twenty group therapy meetings. There are ten Treatment Team Meetings. Appointments are scheduled conveniently between patient and therapist. Appropriate for short term opioid abusers, with limited drug abuse histories. Does not include medications.
- 40 week Individual Opioid Therapy—Complete History & Physical, four blood work/urine analysis, Psychiatric Evaluation, Doctor and Nurse supervision of detoxification and induction to Suboxone or Subutex. You will have 40 individual therapy appointments, one Spiritual Assessment, ten Medical Management appointments, ten Nurse appointments, forty group therapy meetings. There are 19 Treatment Team Meetings. Appointments are scheduled conveniently between patient and therapist. Designed for those who wish to be completely opioid free. Does not include medications.
- Accelerated Opioid Program—Clients are seen for three therapy appointments per week for eight weeks. Four Medical Management appointments. Additionally, there are two group meetings per week and four nurse appointments. There are four Treatment Team Meetings. For out of town patients. Does not include medications.
- Intensive 30 Day Individual or Couples Opioid Therapy—Many people require an intensive program that will allow them to vacation at the same time they reduce drug consumption, includes the following:
1). Six (6) days per week individual therapy. Total of twenty.
2). Four (4) Medical Management appointments.
3). Comprehensive lesson plan with daily preparation assignments.
4). Four nurse appointments and Two Treatment Team Meetings
Services such as detox with supervision, transitional living facility, live in assistance, food allowance and/or ground transportation are available, those additional costs to be determined as needed. Does not include medications.
- 9 Month Couples Opioid Therapy—Couples therapy allows two people to seek treatment at the same time. Many couples who chemically abuse opioids together find that reducing their consumption of opiates at the same time can be more beneficial for themselves and their families. The first two counseling sessions undertaken individually. The curriculum is the same as for individual counseling.
- Annual Opioid or Alcohol Aftercare Program with Group Therapy—Consists of twelve prescription services with Doctor, two complete metabolic profiles (blood work), random drug screens, and attendance at up to fifty group therapy sessions.
- Annual Opioid or Alcohol Aftercare Program with Individual Therapy—Consists of Twelve prescription services with Doctor, two complete metabolic profiles (blood work), random drug screens, attendance at up to fifty group therapy sessions, and twelve individual therapy sessions.
Opioids are powerful pain relievers. The use of methadone for opiate
maintenance in the early 1960s was a major development in combating
the use of heroin. Opium is extracted from the plant Papaver somniferum.
The main active ingredient is alkaloid morphine. Opioids, meaning opiate-
like, are derivatives of opium. All opioids can produce euphoria and can
be used as analgesics. Opioids can be classified as the following:
—Naturally occurring opium derivatives like Morphine
—Partially synthetic derivatives of morphine – Heroin, oxycodone,
—Synthetic compounds – Fentanyl, alfentanil, levorphanol, meperidine,
methadone, codeine, propoxyphene
The term narcotic means drugs producing narcosis or sleep. Although
narcotics do produce sleep, the term does not indicate their major
therapeutic use today.
Opioid receptors in the mammalian CNS include mu, kappa, sigma,
delta, and epsilon subtypes. These receptors are located in the brain
(mostly in the periaqueductal grey), spinal cord, peripheral nerves,
adrenal medulla, ganglia, and gut. Stimulation of mu and sigma receptors
produces intense feelings of well being and euphoria. Kappa-receptor
stimulation produces dysphoria. Antagonists block euphoria produced
The dopaminergic mesolimbic system, which originates in the ventral
tegmental area (VTA) of the midbrain and projects to the nucleus
accumbens, is crucial in the reward effects of intracranial self-stimulation,
the natural rewards of water and food intake, and the action of drugs of
abuse, including opioids. Basal activity of this system, expressed in
dopamine release in the nucleus accumbens, is under the tonic control
of two opposing opioid systems, activation of mu- and sigma-receptors
increases, while kappa-receptor activation decreases the basal activity
of the mesolimbic system.
Experimental evidence with laboratory animals supports the idea that
manipulation of these receptors with opioids and other substances of
abuse (as well as electrical stimulation) affects self-administering behavior.
These reward pathways are thought to have evolved for the natural rewards
such as food and water intake.
A survey by the National Institutes of Health (NIH) demonstrates an upward
trend in new heroin use since 1991. The prevalence of past 30-day heroin
use increased from 68,000 in 1993 to 216,000 in 1996 and is now over
400,000 in 2017. The lifetime prevalence of non-medicinal use of narcotics
is even higher.
According to the National Comorbidity Survey performed in 1990-1992,
20-32% of people who are lifetime heroin users became dependent, while
only 7.5 % of people who used analgesics became dependent. According
to the national, school-base Monitoring the Future Study, the percentage
of 8th, 10th, and 12th graders who have used heroin has more than
doubledsince the late 1990s. This increase has largely been attributed to
decreased price and increased purity in the last decade. Epidemiologic
data indicate that the nonmedical use and abuse of prescription opioids
is increasing in the United States. Results from a surveillance program
called the researched Abuse, Diversion, and Addiction-Related
Surveillance (RADARS) system has determined that OxyContin, a
sustained-release preparation of oxycodone hydrochloride, is the most
commonly abused prescription opioid analgesic. Prevalence of abuse
was rank ordered as follows:
—OxyContin, Hydrocodone, other oxycodone preparations such as
Methadone, Morphine, Hydromorphone, Fentanyl and Roxycodone. The
death rate of people who use opioids is disproportionately high compared
with that of people who use other IV drugs such as cocaine and
—Heroin overdose comprises a substantial component of opioid-related
mortality. Most deaths occur among IV heroin addicts in their late 20s or
early 30s who have used heroin for 5-10 years. A recent period of
abstinence may reduce tolerance and increase risk of overdose, and
addicts have a 7-fold risk of overdosing in the first 2 weeks after leaving
a residential treatment program.
—Violence associated with buying or selling narcotics also causes
mortalities. In some areas of the United States, death rates from drug-
related violence are higher than death rates associated with overdose
—Screening tests for hepatitis A, B, and C are positive in up to 90% of
IV heroin users. HIV infection is also very common in this population, with
rates as high as 60% among heroin users in some areas of the United
—Males abuse opioids more commonly than females, with the male-to-
female ratio being approximately 3:1 for heroin and 1.5:1 for prescription
—New heroin use has a negative association with age. Most people who
are new users of heroin are younger than 26 years, mostly college students.
—Heroin use within the last 30 days was around 0.6 % in people aged
12-17 years, and the incidence of use decreases gradually in older age
groups. The lifetime prevalence of opioid use in people aged 12-17 years
is around 2.3%, and it is slightly higher in people aged 35-44 years because of peak heroin use in the 1960s and 1970s.
EXPLANATION OF TREATMENT SUBOXONE
(buprenorphine HCl/naloxone HCl dihydrate) sublingual tablet.
You will be given a comprehensive substance dependence assessment, as well
as an evaluation of mental status and physical exam. The pros and cons of the
medication, SUBOXONE, will be presented. Treatment expectations, as well
as issues involved with maintenance versus medically supervised withdrawal
will be discussed.
This office will provide your SUBOXONE prescription for the duration of
treatment; these procedures will be explained in more depth at the first visit.
You will be switched from your current opioid (heroin, street methadone or
prescription painkillers) to SUBOXONE or SUBTEX. At the time of
induction, you will be asked to provide a urine sample to confirm the presence
of opioids and possibly other drugs. You must arrive for the first visit
experiencing mild to moderate opioid withdrawal symptoms. Your response
to the initial dose will be monitored. You may receive additional medication,
if necessary, to reduce withdrawal symptoms. Since an individual’s tolerance
and reactions to SUBOXONE or SUBUTEX vary, additional appointments
may be scheduled and medications will be adjusted until you no longer
experience withdrawal symptoms or cravings. Urine drug screening is typically
required for all patients on a random schedule during this phase.
Intake and Induction may both occur at the first visit, depending on insurance
requirements, your needs and your doctor’s evaluation.
Once the appropriate dose of SUBOXONE or SUBUTEX is established, you
will stay at this dose until steady blood levels are achieved. You and your
doctor will discuss your treatment options from this point forward. The amount
of SUBOXONE or SUBUTEX will depend on the amount necessary to
saturate all the affected neurons in the brain. No amount of SUBOXONE or
SUBUTEX above this level will provide any appreciable benefit and this
ceiling effect is beneficial in preventing misuse/overdose potential.
Treatment compliance and progress will be monitored. Participation in
behavioral counseling is required by Federal guidelines and will help to
ensure your best chances for treatment success. Your doctor will monitor your
progress, and you will receive your prescription for SUBOXONE only during
these regular visits. However, if treatment progress is good and goals are met,
monthly visits will eventually be considered sufficient. The Maintenance
phase can last from weeks to years, the length of treatment will be determined
by you and your doctor and possibly, your counselor. Your length of treatment
may vary depending on your individual needs and where possible the
treatment goal to end maintenance on SUBOXONE or SUBUTEX.
Medically Supervised Withdrawal
As your treatment progresses, you and your doctor may eventually decide that
medically supervised withdrawal is an appropriate option for you. In this
phase, your doctor will gradually taper your SUBOXONE or SUBUTEX dose
over time, taking care to see that you do not experience any withdrawal
symptoms or craving.
EXPLANATION OF 1ST DOCTOR MEETING
Your 1st visit is generally the longest, and may last anywhere from 1 to 4
hours. When preparing for your 1st office visit, there are a couple of logistical
issues you may want to consider. You may not want to return to work after
your visit, this is very normal, so just plan accordingly
Because SUBOXONE or SUBUTEX can cause drowsiness and slow reaction
times, particularly during the 1st few weeks of treatment, driving yourself home
after the 1st Med Management Meeting is not recommended, so you must
make arrangements for a ride home.
It is very important to arrive for your 1st visit already experiencing mild to
moderate opioid withdrawal symptoms. If you are in withdrawal, buprenorphine
will help lessen the symptoms. However, if you are not in withdrawal,
buprenorphine will over-ride the opioids already in your system, which will
cause severe withdrawal symptoms.
The following guidelines are provided to ensure you are in withdrawal
for the visit. (If this concerns you, it may help to schedule your first visit
in the morning: some patients find it easiest to skip what would normally be
their first dose of the day.)
—No methadone or long-acting painkillers for at least 24 hours
—No heroin or short-acting painkillers for at least 4 to 6 hours
—Bring ALL medication bottles with you to your 1st appointment.
Before you can be seen by the doctor all of your paperwork must be completed,
so bring all your completed forms with you or arrive about 30 minutes early.
In addition, all agreed contract payments must be paid in advance and it is
your responsibility if your total cost is partially financed, that payments are
made in a timely basis to avoid penalties.
Urine drug screening is a regular feature of SUBOXONE or SUBUTEX
therapy, because it provides physicians with important insights into your health
and your treatment. Your 1st visit will include a review of urine drug screening,
and blood work. If you haven’t had a recent physical exam, your doctor may
require one. To help ensure that SUBOXONE is the best treatment option for
you, your doctor will perform a substance dependence assessment and mental
status evaluation. Lastly, you and your doctor will discuss SUBOXONE and
your expectations of treatment.
After this portion of your visit is completed, your doctor will give you a
SUBOXONE or SUBUTEX prescription. You fill the prescription at the
pharmacy or the doctor’s office so you can take the medication in a safe place
where the medical staff can monitor your response. Your response to the
medication will be evaluated after 30 minutes and possibly again after 1 hour.
Once the doctor is comfortable with your response, you can schedule your next
visit and go home. Your doctor may ask you to keep a record of any
medications you take at home to control withdrawal symptoms.
You will also receive instructions on how to contact your doctor in an
emergency, as well as additional information about treatment.
CHECKLIST FOR 1ST DOCTOR VISIT:
Arrive experiencing mild to moderate opioid withdrawal symptoms
Arrive with a full bladder
Bring completed forms (or come 30 minutes early)
Bring ALL medication bottles
Contracted fee paid in full at time of visit. (Cash, Check or Credit Card)
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The FDA approved Suboxone Film for maintenance treatment of opioid dependence
and should be used as part of a complete treatment plan to include counseling
and psychosocial support. The prescription use is still limited under the Drug Addiction
Treatment Act, however, this innovation helps address compliance challenges:
Suboxone Sublingual Film Dissolve Time—Dissolves faster than the sublingual
tablets presently in use.
a). Suboxone Film dissolves completely under the tongue faster than the
b). In clinical trials, Suboxone Film 8/2 mg dissolved nearly twice as fast as
Suboxone Tablet 8/2 mg.
Suboxone Sublingual Film Taste—Favorable taste rating
a). In a patient questionnaire, more than 71% of patients who tried Suboxone
Film rated the taste as neutral or better on a 10-point scale.
Portability—Compact unit-dose pouches
a). Unit-dose, child resistant pouches are easy to carry
b). Patients who carry Suboxone Film with them should be advised to also carry
their pharmacy label
A patient offer for those that do not have insurance is available. Information regarding
the offer is available at https://www.suboxone.com/treatment-plan/savings-card
Comparable Efficacy and Safety of Suboxone Film to
Clinically the Suboxone Film is interchangeable with the Suboxone Tablet.
• In a clinical study where patients were transferred to Suboxone Film at their
Suboxone Tablet dose
a). The transfer from Suboxone Tablet to Suboxone Film was effective
b). The difference between formulations was not clinically significant
c). 1 out of 176 participants received a dose adjustment (increase) during the first
weeks of the trial
d). Safety trial results indicate that Suboxone Film is well tolerated and has a safety
profile comparable to Suboxone Tablet
• Reduces illicit opioid use and increases treatment retention by suppressing opioid
withdrawal symptoms and reducing cravings
• Once daily dosing due to a long duration of effect, just as with Suboxone Tablet
• A dose adjustment may be needed for patients switching from Suboxone Tablet
to Suboxone Film due to potential individual variability in bioavailability
• The most common adverse event (>1%) associated with the sublingual administration
of the Suboxone Film was oral hypoesthesia. Other adverse events were constipation,
glossodynia, oral erythema, vomiting, intoxication, disturbance in attention,
palpitations, insomnia, withdrawal syndrome, hyperhidrosis and blurred vision.
• Patients are able to transfer from Suboxone Tablet to Suboxone Film easily and
Suboxone Sublingual Film: Helping Address Public
• Child-resistant unit-dose packaging
a). Pouches achieved a high level of child resistance
b). Unit-dose packaging to reduce the risk of multi-dose exposure
• Suboxone Film formulation discourages misuse and abuse
a). Suboxone Film formulation makes it difficult to crush into a powder and snort
b). Suboxone Film contains naloxone. If injected, noxalone attenuates the effects
of buprenorphine and precipitates withdrawal in individuals dependent on
full opioid agonists, but has no effect when taken sublingually
• Protecting treatment through a Risk Evaluation and Mitigation Strategy (REMS)
a). REMS consists of a set of tactics designed to help promote the appropriate
use of buprenorphine and help protect the in-office treatment of opioid
• Includes various materials and processes developed to assist in:
a). Mitigating the risk of accidental overdose, misuse, and abuse
b). Informing patients of the serious risks associated with buprenorphine
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