Author Archives: Joshua Brow

Sublocade Treatment for Narcotic Addiction

Many patients suffering from narcotic addiction and dependency are familiar with Suboxone tablets, film and Subutex. These are various form of Buprenorphine that is used to control the withdrawal symptoms associated with addiction to narcotics. Suboxone is a partial agonist and antagonist medication. What that means is that it acts as a narcotic and also has protection against excessive narcotic intake. Sublocade is a new FDA approved form of Buprenorphine that is extended- release and activated by injection into a subcutaneous area of the abdomen. When injected, it forms an implant that slowly released the Buprenorphine over a period of one month or longer.
Sublocade is administered only by a healthcare provider that is familiar with the injection process. It is used to tread adults with moderate to severe addiction to opioid drugs regardless of obtained by prescription or illegally. The medication is injected as a liquid under the skin of the abdomen (stomach). It forms an implant under the skin known as a “depot”. The “depot” may be felt as a small bump under the sin for about several weeks. As with all addiction, Sublocade is only a part of a complete treatment plan that will also require counseling.
INDICATION AND USAGE
SUBLOCADE is indicated for the treatment of moderate to severe opioid use disorder in patients who have initiated treatment with a transmucosal buprenorphine-containing product followed by a dose adjustment period for a minimum of seven days.
SUBLOCADE should be used as part of a complete treatment program that includes counseling and psychosocial support.
WARNING: RISK OF SERIOUS HARM OR DEATH WITH INTRAVENOUS ADMINISTRATION; SUBLOCADE RISK EVALUATION AND MITIGATION STRATEGY
• Serious harm or death could result if administered intravenously. SUBLOCADE forms a solid mass upon contact with body fluids and may cause occlusion, local tissue damage, and thrombo-embolic events, including life threatening pulmonary emboli, if administered intravenously.
• Because of the risk of serious harm or death that could result from intravenous self-administration, SUBLOCADE is only available through a restricted program called the SUBLOCADE REMS Program. Healthcare settings and pharmacies that order and dispense SUBLOCADE must be certified in this program and comply with the REMS requirements.
IMPORTANT SAFETY INFORMATION
Prescription use of this product is limited under the Drug Addiction Treatment Act.
CONTRAINDICATIONS
SUBLOCADE should not be administered to patients who have been shown to be hypersensitive to buprenorphine or any component of the ATRIGEL® delivery system
WARNINGS AND PRECAUTIONS
Addiction, Abuse, and Misuse: SUBLOCADE contains buprenorphine, a Schedule III controlled substance that can be abused in a manner similar to other opioids. Monitor patients for conditions indicative of diversion or progression of opioid dependence and addictive behaviors.
Respiratory Depression: Life threatening respiratory depression and death have occurred in association with buprenorphine. Warn patients of the potential danger of self-administration of benzodiazepines or other CNS depressants while under treatment with SUBLOCADE.
Neonatal Opioid Withdrawal Syndrome: Neonatal opioid withdrawal syndrome is an expected and treatable outcome of prolonged use of opioids during pregnancy.
Adrenal Insufficiency: If diagnosed, treat with physiologic replacement of corticosteroids, and wean patient off of the opioid.
Risk of Opioid Withdrawal With Abrupt Discontinuation: If treatment with SUBLOCADE is discontinued, monitor patients for several months for withdrawal and treat appropriately.
Risk of Hepatitis, Hepatic Events: Monitor liver function tests prior to and during treatment.
Risk of Withdrawal in Patients Dependent on Full Agonist Opioids: Verify that patient is clinically stable on transmucosal buprenorphine before injecting SUBLOCADE.
Treatment of Emergent Acute Pain: Treat pain with a non-opioid analgesic whenever possible. If opioid therapy is required, monitor patients closely because higher doses may be required for analgesic effect.
ADVERSE REACTIONS
Adverse reactions commonly associated with SUBLOCADE (in ≥5% of subjects) were constipation, headache, nausea, injection site pruritus, vomiting, increased hepatic enzymes, fatigue, and injection site pain.
About Opioid Use Disorder
OUD, commonly referred to as opioid addiction8, is a chronic, relapsing disease that changes the brain9. According to the DSM–5, opioid use disorder is characterized by signs and symptoms that reflect compulsive, prolonged self-administration of opioid substances that are used for no legitimate medical purpose or, if another medical condition is present that requires opioid treatment, they are used in doses greatly in excess of the amount needed for that medical condition13.
Based on 2016 data from the most recent National Survey on Drug Use and Health report, nearly 12 million Americans (age 12+ years) engaged in misuse of opioids in the last year6. Between 1999 and 2014 the rate of deadly opioid overdoses quadrupled14, and in the United States alone, an average of four people die of opioid overdose every hour of every day7. In 2015 opioids accounted for 70 percent of the negative health impact associated with drug use disorders worldwide15. Approximately 2.5 million American adults (age 18+ years old) met criteria for opioid use disorder in the past year10. The same report suggested that 935,000 adults have used heroin in the past year and 471,000 used in the past month. There were approximately 625,000 adults who had a heroin use disorder in the past year6. In a recent report by the White House Council of Economic Advisers, estimated economic costs of the opioid crisis in the U.S. were $504 billion in 201512.
About Indivior
Indivior is a global specialty pharmaceutical company with a 20-year legacy of leadership in patient advocacy and health policy while providing education on evidence-based treatment models that have revolutionized modern addiction treatment. The name is the fusion of the words individual and endeavour, and the tagline “Focus on you” makes the Company’s commitment clear. Indivior is dedicated to transforming addiction from a global human crisis to a recognized and treated chronic disease. Building on its global portfolio of opioid dependence treatments, Indivior has a strong pipeline of product candidates designed to both expand on its heritage in this category and address other chronic conditions and co-occurring disorders of addiction, including alcohol use disorder and schizophrenia. Headquartered in the United States in Richmond, VA, Indivior employs more than 900 individuals globally and its portfolio of products is available in over 40 countries worldwide. Visit www.indivior.com to learn more.

Dr. Jagodowicz provided this service and has found that treatment with Sublocade can provide a long term solution to gradual withdrawal from opioids with a series of a few injections that are performed in the office setting. The abdominal injection of the Sublocade is relatively painless and results In blockade of the receptor sites for other narcotics such as “Heroin”. With proper counseling, this may offer a solution for some patients with moderate to severe addiction.

For more information, Contact our office at (818) 360-4949

Morris Jagodowicz, M.D.

Narcotic Dependency

 

It all starts with a remedy for pain relief, or in the pursuit of pleasure. Some people become dependent on narcotics to help with their back or neck pains, others turn to drugs for their euphoric effect.  Pleasure or relief is what we are after.  Some people climb mountains, ski, or eat excessively. Some drink coffee, eat chocolate, smoke cigarettes, drink alcohol, or do drugs.  These all produce euphoria by turning on the reward activation system of the brain. This system sends increased dopamine into the frontal lobes of the brain and serotonin into the rest of the brain’s cortex. These chemicals make us feel good.  The dopamine can inhibit the activity of our frontal lobes, which dampens our critical reasoning and judgment, resulting in feeling uninhibited.. We might dance, get silly, or do crazy things. Almost all drugs that are abused turn on this reward activation system and produce euphoria. The problem is that we cannot maintain this state and we feel bad afterwards.

 

THE ADDICTIVE PERSONALITY

Why are some people more prone to becoming addicted to narcotic drugs? Is it a part of their genetics or a particular set of personality traits that make an individual predisposed to addiction? People with substance dependency are frequently at a higher risk of becoming addicted to gambling, food, pornography, exercise, compulsive buying, and excessive cell phone and internet-computer use.  What are the common traits between all addictions? Although, there may be some generalities in this list, the addictive personality usually displays signs of impulsive behavior, weak commitment to achievement of goals, sensitive to stress, lack self-esteem, seek peer-approval, extraversion, self-monitoring, and loneliness. Stress, depression, anxiety disorder, obsessive personality, and attention deficit disorder are all related to the addictive personality.

Chemically speaking, the opioid-dependent person has less dopamine release in the brain.  This dopamine can be artificially created by narcotics, cocaine, nicotine, or alcohol. This delivers the feeling of well being or self-soothing in stressful situations.

 

REWARD ACTIVATION SYSTEM

The reward activation system is what keeps us happy.  This is what keeps us feeling good.  It does this by increasing dopamine into the frontal lobes of the brain and serotonin into the rest of the brain.  The dopamine can inhibit activity in the frontal lobes and dampen our critical reasoning and judgment.  A dopamine surge corresponds to a euphoric high.  In short, our judgment might be impaired and we feel uninhibited.  We might do risky or crazy things. We are in pursuit of turning on the reward activation system.  Narcotics, as well as coffee, smoking, and alcohol can do this. The problem is that this state of euphoria can’t be maintained and we usually feel bad afterwards.

 

THE PAIN JUST KEEPS GETTING WORSE

Assuming that some people started using narcotics for a pain condition such as back or neck pain, the medication at first worked well in decreasing the pain.  As tolerance to the narcotic occurs, more and more medication is needed to control the pain.  After some time, attempts to decrease the medication, results in severe pain that was worse than the original condition.  This is because withdrawal symptoms of severe body aches played on the overall condition.  The answer was always, I need more medication from my doctor because the drugs are no longer working. When in fact, it’s the development of tolerance to the drug and not being able to obtain additional quantities, that results in withdrawal. This causes severe aches and pains.  High opiate levels cause pain sensitivity to increase. Substance dependence, is a drug user’s compulsive need to us narcotics in order to function normally. When such substances are unobtainable, the user suffers from withdrawal symptoms. In opiate withdrawal, everything hurts. Even normal uninjured parts of the body hurt. This declines gradually over a 1-3 month period and the pain threshold comes back to normal.  The important thing is to realize that there is a problem.

 

OPIATE WITHDRAWAL

Adrenaline is a natural substance in the body that helps us cope with stress and increased activity.  Opiates dampen this response to adrenaline.  This may result in sleepiness. If there is enough opiates in the system, we stop breathing and die. This is known as overdose.  The body adapts to opiates by increasing adrenaline levels. This helps prevent respiratory depression and makes the person more tolerant to higher doses.  When the opiate is stopped, the high levels of adrenaline cause withdrawal symptoms as sweats, watery eyes, runny nose, yawning, muscle twitching, and irritability. There may even be a tendency for panic attacks.

 

THE BIG LIE

We assume that the drug effect is gone when the high goes away.  The truth is that a drug induced high is followed by a low.  With repeated use, the high weakens and the low gets stronger.  A good example is cocaine.  It gives you a brief “high” followed by a depressed state.  Despite knowing that the drug is causing their bad feelings of withdrawal, pain and fatigue make people vulnerable to losing control. They go out to get more of the drug to fix the situation.. Thus begins an addiction. The person no longer has command or control over their use of the drug. The drug takes control, and all problems are interpreted as the result of too little or too much drug.

 

THE HIGH ALWAYS GOES AWAY

The high goes away and the user gradually settles down to just trying to “maintain” being normal and avoiding withdrawals “being sick”.  The trick is to gradually wean off the opiates.  Many addicts use alcohol to dampen withdrawal symptoms, and may settle into a life of alcoholism. Long acting mixed narcotics used for treating dependency, such as Suboxone, are helpful in the weaning process.

No method is perfect for treating addiction. Whether you use abstinence, Methadone or Buprenorphines (Suboxone, Subutex, or Zubsolv), the failure rate remains high.  Being motivated helps improves the numbers.  Buprenorphine activates opiate receptors only part way and stays for a long while.  Other long acting opiates such as Methadone make it easier to avoid withdrawals, but tend to be abused and can result in overdosing.  Suboxone has a ceiling effect.  This makes it unlikely that an experienced opiate user will overdose.  In fact, patients treated with Suboxone for over one year have a very low mortality rate. Using any more than 12-24 mg daily sublingual has no psychological benefit.  Suboxone and Zubsolv are formulations of Buprenorphine plus Naloxone. They dampen the roller coaster on and off cycle of opiate addiction and blocks the craving associated with opiate withdrawal.  With education, effective counseling, patients can be tapered slowly off Buprenorphines This should be the goal. A newer product such as Sublocade is an injectable form of Buprenorphine that lasts for months.

 

MORRIS JAGODOWICZ, M.D.