First Posted 1/26/2014
I recently answered a post at SuboxForum by a member who asked what to expect from rapid detox from opioids, and specifically from buprenorphine.
Several of my current buprenorphine patients have been through rapid detox at some point in their past. Their stories are so similar that it becomes difficult to distinguish one from the next. A typical history would go something like this:
“I started pot and alcohol by 16, but discovered pain pills when I was about 17 when I had surgery. My doctor gave me pain pills when I hurt my back, and when he stopped, I started getting them from my aunt’s house. She had cancer so she had tons of them. Then she died, and I was getting them from friends at work until they got more expensive. I switched to heroin a couple years ago.”
I’ll ask, “have you been through treatments?”
“Yep– detoxed 3 times, twice to rehab, once for 30 days and once for 3 months…. I did NA on and off, and was on methadone for a couple years. Oh, and I did rapid detox in Florida 5 years ago.”
I’ll ask, “what is the longest you stayed clean?”
“I was clean most of the time when I was in rehab… so maybe 2 months? other than that it would be a few days here or there– usually not more than 3 days. After rapid detox I stayed clean for 2 months because I didn’t have any money left to buy anything.
I’ll ask, “Have you been on Suboxone before? Any time totally off opioids?”
They’ll say “I was on it for 1 year but I stopped. Not sure if I was ever totally clean… there was always something around.”
I don’t mean to be flippant about relapse, especially given the high rate of death associated with relapse to opioids. But I want to give an idea of how my attitudes about buprenorphine were formed over the years. Patient after patient have provided stories about repeated relapses despite a variety of treatment efforts, including rapid opioid detox.
During my own period of active using in the early 1990′s, desperation drove me to my own ‘rapid detox’, without the anesthesia. I kicked off my ‘clean time’ with IV naloxone, followed by a couple 50 mg tabs of naltrexone. I had stopped opioids for several days, so I didn’t expect severe withdrawal…. but was I wrong! I could walk by the end of day one, just barely, but I remained very sick for a week or two. I’m sure I would have stayed sick at least a few weeks longer, had I stayed clean…. but as soon as I realized that I had made it through such a nightmare alive, I decided that I must have some awesome will power, and I could always just do that again, if I had to…. so I ‘rewarded’ myself with a bit more controlled using.
As I see it, the problem is that the person who walks out of the door of rapid detox is not all that different from the person who walked in. Yes, the person had his mu opioid receptors antagonized for a day. But that’s not long enough to get one’s receptors back to normal, not by a long shot. After a day or two of naltrexone, patients still have weeks of withdrawal awaiting them.
What if a person stays on naltrexone for the entire several months that it takes for tolerant opioid receptors to be replaced by new, normally-sensitive opioid receptors? That would be a better option than rapid detox alone, reducing the odds for relapse by blocking receptors during the most intense physical cravings.
But in reality, addiction is much more complicated than physical cravings. Despite the promises of a new life in ads for detox programs, naltrexone is not fairy dust that changes how a person deals with good and bad news. Most people who seek detox have been conditioned, for years, to use opioid in response to resentments. So the person who picked up at age 18, 20, 25, and 28 tends to pick up again, unless something makes a real difference in how the person responds to life’s challenges. For most people, I do not believe that rapid detox makes enough of a difference.