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UConn Today sat down with Dr. Lakshit Jain, clinical associate professor in the Department of Psychiatry at UConn Health, to learn more about what’s really involved in withdrawal from opiate addiction and what opioid use disorder sufferers and your loved ones stay safe and make sure they get the right care. Jain, along with UConn Health co-authors Dr. Vania Modesto-Lowe and former psychiatry resident Dr. Roberto León-Barriera, just published a letter to the editor in The Primary Care Companion for CNS Disorders titled “ Mindfulness Training in Opioid Withdrawal: Does it Help?”

Dr.  Portrait of Lakshit Jain (outdoor)Dr. Lakshit Jain is a Clinical Associate Professor in the Department of Psychiatry at the UConn School of Medicine. (Photo provided by Lakshit Jain)

Q: What is opioid use disorder?
Opioid use disorder (OUD) is not just an individual who uses a lot of opioids to “get high”; refers to a problematic pattern of opiate use that leads to clinically significant impairment or distress, manifested by a persistent desire or unsuccessful efforts to reduce opiate use, making great efforts and spending a lot of time activities necessary to obtain the opioid. using the opioid or recovering from its effects; strong desires/desire/impulse to use; failure to fulfill the main vital obligations at work, at school or at home (losing a job, dropping out of school, etc.); continued use despite persistent or recurring social or interpersonal problems (divorce, separation, loss of child custody, etc.); using opioids in dangerous situations (drunk driving, etc.); and giving up important social, work, or recreational activities to use opioids.

Q: What is the prevalence of OUD in the US?
Opioid use disorder in the United States has been a triple-wave phenomenon driven by the growing popularity of prescription opioids, heroin, and synthetic opioids, respectively. It is often interpreted as people developing an opioid use disorder when they were receiving opioid prescriptions from their health care provider or stealing opioid prescriptions from a family member who was receiving them from a provider; and then turned to heroin when prescriptions expired or stopped.

In the US, an estimated 5.7 million people (2.1% of people aged 12 and over) in 2019 had used heroin at some point in their lives, and 431,000 (0.2%) had report last month. Between 2002 and 2018, the prevalence of heroin use and heroin use disorder nearly doubled.

Q: How dangerous have illegal opioids become?
To: Beginning in 2013, Illicitly Manufactured Fentanyl (IMF) began to gain popularity in the US, both in its pure form and mixed with heroin, as fentanyl is 30 to 40 times more potent by weight than heroin and it’s cheaper. Fentanyl has led to a significant decrease in the cost of opioids, and because the high potency of MFI can cause a rapid overdose, which is demonstrated by the fact that 56% of the dead do not have a pulse when first responders arrive.

This rise in opioid use disorder has led to a national pandemic of opioid overdose deaths, with more than 100,000 estimated drug overdose deaths in a 12-month period for the first time, with more than 64% of ‘these deaths with fentanyl. According to the CDC, the age-adjusted rate of overdose deaths nationwide increased significantly by 9.6% from 2016 (19.8 per 100,000) to 2017 (21.7 per 100,000). Opioids, primarily synthetic opioids other than methadone, are currently the leading cause of drug overdose deaths. Opioids were involved in 47,600 overdose deaths nationally in 2017. This number represents 67.8% of all drug overdose deaths in the United States.

Q: What do patient-reported as challenging withdrawal symptoms or opioid withdrawal feel like?
To: Patients experiencing opioid withdrawal often experience extremely strong flu-like symptoms, and some refer to this as the “super flu” or “the flu on steroids.” These include severe muscle pain, tearing, runny nose, nausea, vomiting, abdominal cramps, diarrhea and restlessness. These make strong, constant cravings for an opioid worse.

Opioid withdrawal begins almost immediately if naloxone is used to revive someone on the street or in an emergency room, and signs and symptoms of withdrawal begin 4 to 12 hours after the last dose of an opioid short-acting and often delayed from 24 to 24 hours. 48 hours after stopping a long-acting opioid such as methadone. Withdrawal symptoms usually peak 24 to 48 hours after onset and persist for several days with short-acting agents and up to two weeks with methadone.

Severe withdrawal can cause an increase in heart rate, blood pressure, and respiratory rate. Severe vomiting and diarrhea can cause fluid loss and low blood pressure. Although they can be controlled, the cravings continue to worsen, forcing the patient to seek out more opioids and use them to lessen the cravings.

Q: Where should patients seek help?
To: Patients experiencing mild to moderate opioid withdrawal should contact their primary care providers, as there are ways to help patients participate in treatment with medications such as methadone and buprenorphine

If the withdrawal is severe (rapid heart rate, fainting, difficulty breathing, etc.) they should be presented to the nearest ER.

Q: What treatments have proven to be most effective?
To: Treatment of opioid use disorder is multifocal, involving several treatment strategies that are often used together in a specialized treatment center. This includes:

  1. Pharmacological management: These include opioid agonists (buprenorphine or methadone) and opioid antagonists (ie, naltrexone). Buprenorphine is preferred for mild to moderate opioid use disorders and methadone is preferred for people with high tolerance (people who use high doses of opioids to get the desired effect). In individuals unable or unwilling to take agonist treatment, naltrexone is a reasonable alternative; however, people who will be treated with naltrexone need medically supervised withdrawal before starting an antagonist.
  2. Psychotherapy: includes the following interventions:
    1. Counseling or cognitive behavioral therapy (CBT), including variants such as acceptance and commitment therapy and motivational interviewing.
    2. Behavioral interventions such as contingency management that use incentives and other reinforcements to increase participation in treatment and decrease substance use. Contingency management is usually added to other interventions such as (CBT). It has generally been found to be effective in opioid use disorder.
    3. Mutual aid groups such as Narcotics Anonymous or Methadone Anonymous.
    4. Training or involvement in communities such as drug-assisted recovery services.

Q: Can mindfulness help patients fight opioid withdrawal?
To: In some addiction settings (inpatient and outpatient), patients are exposed to mindfulness training (MT) in individual and group settings to decrease stress, cravings, and cue reactivity. MT also appears to have positive effects on various types of pain, including pain in patients with addiction. Anecdotal evidence suggests that MT may be particularly helpful during withdrawal states, despite scant empirical data to support this view.

Q: Along with prevention, what promising new treatments are on the horizon to help curb our nation’s opioid addiction epidemic?
To: A new implant called Probuphine was approved by the US Food and Drug Administration (FDA) in 2016. It consists of a one-inch rod that a doctor inserts into the inside of the upper arm. This implant provides a constant dose of buprenorphine that can last up to six months with multiple rods.

Additionally, in 2017 the FDA approved Sublocade, which is a once-monthly injectable formulation of buprenorphine. Patients who have been on a stable dose of buprenorphine treatment for at least seven days can choose to receive this injection once a month. In 2018, the FDA approved Lucemyra (lofexidine hydrochloride) to reduce the severity of opioid withdrawal symptoms and to facilitate the abrupt discontinuation of opioids in adults. It works by a mechanism similar to clonidine.

In addition to the new treatments, the Department of Health and Human Services (HHS) is releasing new buprenorphine practice guidelines that lower barriers for providers to treat more people. Also, in 2018, the National Institutes of Health (NIH) launched the Long-Term Initiative to Help End Addiction (NIH HEAL Initiative). It’s an “aggressive, transagency effort to accelerate scientific solutions to curb the nation’s opioid public health crisis.” It aims to support multiple institutes to accelerate research to address this public health emergency from all angles.

Source: Opioid Addiction and Withdrawal: What You Should Know

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