Ready to get off opioids? How to make recovery stick

It takes a village: Evan Figueroa-Vargas (right), homeless services program manager for the Mental Health Association of Southeastern Pennsylvania, hugs a homeless man in Kensington. Figueroa-Vargas grew up nearby, became an addict, went to prison and has now been clean for six years.

There are a couple of things that everyone should know about recovery from addiction: It takes a village. And it takes a lifetime.

Viewed that way, the failures, the repeat admissions, the relapses, are bumps on the road — although when a bump involves opioids, it can quickly turn into a fatal overdose. Keep in mind the big picture if you are trying to help a friend or loved one recover from opioid addiction.

It also is important to remember that there are numerous paths to success. Still, experts we spoke with say there are some basic tips that may help you and your loved ones find a route to recovery, and stay on it. Here are a few questions you may have as you start the process:

What if they're not ready to get clean?

“Express concern,” said addiction psychologist John F. Kelly, director of the Research Recovery Institute in Boston. “Be persistent. And get outside help for yourself.” There are many support groups online, including Learn2Cope. The Partnership for Drug-Free Kids (855-378-4373) offers free coaching for parents, by parents. You can also download the evidence-based 20 Minute Guide; both the guide and training for the lay coaches are from the Center for Motivation and Change, a treatment organization in New York and Massachusetts. Meanwhile, buy the emergency opioid-overdose reversal medication naloxone at a pharmacy that carries it; Pennsylvania and New Jersey have both issued standing prescriptions that allow it to be dispensed without an actual prescription from a doctor.

Try to understand the fears of people who are avoiding treatment. If pain is an issue – and many people who are taking these drugs say that it is – “that person will be very afraid,” said Andrew Kolodny, codirector of opioid policy research at Brandeis University’s Heller School for Social Policy and Management. And opioid withdrawal is no minor thing, he said: “People feel like they are going to die.”

Can they get into treatment right now?

There will likely be a wait, but they can be assessed immediately — evaluated to determine the appropriate type and level of treatment. Treatment providers can do that, but so can other centers that are not affiliated with any of them. Every Pennsylvania and New Jersey county has a drug and alcohol agency that may be able to refer you. Experts say many people who are addicted to some drugs can recover on their own, although "natural recovery" is far more difficult with prescription opioids (and almost impossible for heroin).

How do we pick a program?

The vast majority of places that call themselves treatment centers are not licensed and do not use practices based on research. Kelly, whose institute is a joint project of Massachusetts General Hospital and Harvard Medical School, suggests asking several questions. The specific answer may not matter as much as the ability to answer at all. “No” to any of them should be a red flag. So should any professional treatment provider that accepts payment only in cash. Ask: Are you accredited? Do you have certified addiction specialists or an addiction psychiatrist on staff? Do you conduct a comprehensive assessment using validated measures? Can you name them? A key question: Do you offer medication-assisted treatment?

"Twelve-step treatments and community mutual-help organizations like AA and NA can be helpful, but little is known specifically how effective these are alone for opioid addiction," Kelly said. 

A 12-step program alone “is not treatment. It’s help,” said clinical psychologist Jeff Foote, executive director and cofounder of the Center for Motivation and Change. Some people appreciate the supportive structure and ideology; others feel suffocated.

For a far more complete look at the industry, read Anne M. Fletcher's Inside Rehab: The Surprising Truth about Addiction Treatment - and How to Get Help that Works.

What about health insurance coverage?

Despite all the talk about insurance parity between physical and behavioral health needs, many families report that they don't have as much coverage from private insurers or Medicaid as they believe that they need. Kelly suggests his website’s section on navigating the insurance landscape, though requirements differ by state. 

Why add drugs if the goal is to be drug-free?

Research suggests that medication-assisted treatment significantly reduces the likelihood of relapse. The largest study, published in 2015, found that after 3½ years, patients who started suboxone were nearly twice as likely as those who did not to report not having used opioids in the previous month. Comprehensive treatment centers usually offer more than one type of medication; many others use it for a short time during and after detox, if at all.

Kolodny compared recovering from a serious opioid addiction without medication to overcoming type 2 diabetes without medication: “Most people can’t do it.” Foote advised staying on maintenance medication for at least a year or two and perhaps longer; the added support  provides breathing room to rebuild one’s life, and there is no harm to using such medicines, he said.

There are three types of medication:

  • Methadone has a decades-long track record as a long-term maintenance medication. Considered an opioid agonist, it replaces the drug of abuse, preventing horrific withdrawal pains while also avoiding the euphoric effects of other opiates. It is highly regulated, requiring daily visits to a clinic — a major annoyance for many people but a lifesaving structure for others, especially when they can receive behavioral counseling at the clinic.
  • Suboxone, the most commonly prescribed form of the partial agonist buprenorphine (it is combined with naloxone, making it harder to abuse), works similarly to methadone but doesn't require a daily clinic visit. Adding to its popularity is that it can be prescribed monthly by physicians who are certified; behavioral counseling, which many addiction specialists believe is important to a sustained recovery, often is separate.  
  • Vivitrol, a brand-name version of extended-release naltrexone, is an opioid antagonist; rather than replacing opioids it blocks the brain’s opioid receptors, so people with opioids still in their system will immediately go into withdrawal that may be painful. What started as a daily pill is now most common as a monthly injection, which was approved in 2010 and can be prescribed by any health-care provider; counseling is recommended.

What follows treatment?

Release is the most dangerous time in recovery because the body’s built-up tolerance for opioids drops after a period of abstinence, but the person may feel just as tempted by his or her drug of choice as ever. Going without supportive medication at release “kills people,” Foote said. Patients need their family’s support, too, just as they would after being released from a hospital after an organ transplant. Comprehensive treatment centers typically release patients in steps – going from a residential program, say, to a “partial hospitalization” and then to intensive outpatient care.

Some people who entered treatment after a devastating downward spiral find that a new environment — new city, new friends, new job — can help protect them from the triggers they associate with drug use. Others would miss the support back home. Sober living environments, also known as recovery houses, may be an in-between option.

What should you expect in the first year of recovery?

“People need to know that the first 90 days are absolutely critical,” Kelly said, requiring daily coaching and support. It often takes 180 days “for the brain to recalibrate.” Stress hormones increase and changes in the central nervous system dull the ability to perceive and experience reward. “Where you used to enjoy being with friends, seeing a movie, going for a walk,” he said, “they just don’t seem as fun anymore.”

Frequent meetings for support, whether they are part of a therapy program or Narcotics Anonymous or other self-help programs, are essential. For treatment to be successful, it should continue in some form for 90 days to a year, depending on the duration of addiction, the drugs used, genetics, and environment. Generally, people who are well-educated and have jobs and good family support are at a lower risk of relapse, Kelly said.

And five years out?

People who stay clean for four or five years have about the same risk of developing a substance abuse problem as the general population, Kelly said.

Even then, people in recovery should see a professional at least quarterly, and continue creating networks that support them rather than pulling them back toward addiction.

The rest of your life

For some people, identifying as a person in recovery can be empowering. For others, it can be stigmatizing. Successful recovery does not mean never relapsing. You just learn how to come out the other side.  

“Understand that this is really hard. We think of this as a process of mastery,” said Foote, who doubles as a sports psychologist. “You don’t just become a better batter by wanting to be. ... You improve your game by actually improving your process,” he said.

“It is an incredibly hard thing to do. Living a constructive life is a lifetime job.”

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