By Britt Parramore LPC, CAADC
An examination of different treatment methods for use with those diagnosed with an opioid use disorder will be examined and compared. Specifically, pharmacotherapeutic treatments using the partial agonist opioid buprenorphine will be examined. The 12-step treatment method will also be examined and will be compared to treatments using buprenorphine. Lastly, a Christian Worldview in regards to the use of both therapies will be given and recommendations made.
“Opioid use disorder includes signs and symptoms that reflect compulsive, prolonged self administration of opioid substances that are used for no legitimate medical purpose” (DSM-5, 2013, p. 483). Opioids are very similar to opiates. Both affect opiate receptors in the human body in the same way. The difference lies in whether the drug is synthetic or natural. Opiates are a natural derivative of the opium plant, while opioids are synthetic in nature. The DSM-5 (2013) makes no distinction between opiates and opioids, and thus opioid use disorder is the diagnostic label applied to persons addicted to both substances. Therefore, for the purposes of this research assignment, opioid will be used to describe both opiates and opioids.
Opioids are extremely addictive and addiction to, or dependence on opioids is a chronic relapsing disorder. Heroine is the most commonly abused opioid, but it is by no means the only one; others include morphine, codeine, hydrocodone, oxycodone, fentanyl, buprenorphine, methadone, and opium, along with other derivatives of these. Unfortunately, a large number of people become addicted to opioids through misuse of prescriptions. Many times, a patient will receive a prescription of an opioid for pain and will develop tolerance and dependence (Praveen, et al., 2011). Because of this, opioid dependence is becoming a problem of national concern in the United States; especially considering the dramatically increased rates of abuse and dependence of individuals to prescription opioids (Veilleux, et. al., 2009). The DSM-5 (2013) uses the following diagnostic definition to describe the characteristics of an opioid use disorder:
“Opioid use disorder include signs and symptoms that reflect compulsive prolonged self administration of opioid substances that are used for no legitimate medical purposes or if another medical conditions present the requires opioid treatment that are used in doses greatly in excess of the amount needed for that medical condition” (p. 542).
The prevalence of opioid use amongst people aged 15 to 64 in the United States has remained relatively constant at 0.4% over the past 10 years. The lifetime prevalence rates are a bit higher though. They indicate that 1.7% of people between ages 19-30 have tried heroin and 18.7 have used other opioids with hydrocodone and oxycodone the two most popular opioid prescription drugs (Veilleux, et. al., 2009). Most shocking however, is the four-fold increase in the number of high school aged children who report abusing opioids, making it the second most abused drug behind marijuana (2009).
Common Therapies for Opioid Use Disorders
There are certainly a growing number of empirically supported treatments for those diagnosed with an opioid use disorder in America currently. For the purposes of this research paper, two empirically supported treatments will be examined. First, the pharmacotherapy using buprenorphine will be examined. Next, the 12-Step method will be examined.
Over the past two decades, much research has been done on the biological basis of the addictive process. This has led to the development of a number of pharmacological agents used to interrupt the addictive process at its various stages. These stages include; the initiation of substance abuse, the transition from abuse to dependence, and the prevention of drug reinstatement or relapse (Ross, Peselow, 2009). These are known as pharmacotherapeutic approaches. Pharmacotherapeutic approaches to opioid use disorder treatment use medication as the primary catalyst for treatment. Specifically, opioid agonist, partial agonist, and opioid antagonist are used. For the purposes of this research project, the partial agonist opioid buprenorphine will be examined.
Buprenorphine, sold under the brand names Suboxone and Subutex, is a partial agonist opioid used in the treatment of patients who are dependent on opioids. Suboxone is the most widely used formulation of buprenorphine in America today. It exists in its currently approved form as a combination of buprenorphine and naloxone. Naloxone is an opioid antagonist although bioavailability is only possible when administered intravenously. Naloxone is added to buprenorphine as Suboxone for the purpose of preventing abuse. If an addicted person attempted to crush and inject Suboxone, the naloxone would cause immediate withdrawal to occur (Ducharme, et. al., 2012). As a treatment for opioid dependence, buprenorphine is an extremely effective medication at its current stage of development (Ling, 2009). Unlike methadone, buprenorphine dosing can be adjusted to a patients needs with minimal potential for severe consequences. In addition to being a relatively safe medication, buprenorphine has a relatively low abuse potential, making it desirable for prescribing doctors. The approval of buprenorphine as a pharmacotherapy for opioid dependence gives physicians the ability to treat their opioid dependent patients with an effective, opioid-based treatment. Buprenorphine is an opioid, however, and potential for misuse is far less than opioids used to treat pain. This is due to the fact that buprenorphine is a partial, rather than a full agonist opioid (2009).
Buprenorphine is a partial agonist opioid. “This means that, although buprenorphine is an opioid, and thus can produce typical opioid agonist effects and side effects such as euphoria and respiratory depression, its maximal effects are less than those of full agonists like heroin and methadone” (Buprenorphine, 2013). Buprenorphine is used by doctors at low doses to enable opioid-addicted individuals to stop the misuse of opioids without having to experience the severe withdrawal symptoms associated with the discontinuation of most full agonist opioids. Associated with the use of Buprenorphine is what is known as the ceiling affect. This simply means that at some dose, which is idiosyncratic to the individual, the narcotic effects of buprenorphine cease, and all the user is left with is a method of withdrawal prevention. Thus, buprenorphine has a much lower abuse potential as compare to full opioid agonist. “In fact, in high doses and under certain circumstances, buprenorphine can actually block the effects of full opioid antagonists and can precipitate withdrawal symptoms if administered to an opioid-addicted individual while a full agonist is in the bloodstream” (Buprenorphine, 2013).
Buprenorphine Treatment & Research
Buprenorphine was approved in the U.S. and, has been used since 2002 in a number of different clinical settings. The purpose of this section is an examination of research in different treatment settings for the purpose of determining the best possible treatment use of buprenorphine. The two treatment uses of buprenorphine that will be examined are: long term use in both inpatient and outpatient settings, and brief buprenorphine detoxification.
A study done in 2001 compared the long term use of buprenorphine in 3 treatment settings: an inpatient opioid treatment program offering individual counseling, a group counseling program utilizing cognitive behavioral treatment in an outpatient setting, and a private clinic setting where only buprenorphine was used with no psychotherapeutic approaches (Miotto et. al., 2012). The study was done over a 52-week period and thus should be considered long term in regards to the buprenorphine treatments being considered for the purposes of this paper. The FDA did the study for the purposes of drug approval protocol.
Research showed similar outcomes in regards to opioid use across all three studies. Unfortunately, 22% of patients dropped out of the programs in the first three days. This illustrates the importance of early engagement of patients receiving treatment for opioid addiction (2012). Only one quarter completed the entire 52-weeks. The intention of all three studies was that the patients would gradually taper off buprenorphine with the goal of being completely off by the end of the 52 weeks. Of the 124 participants who began the treatments, only three were able to successfully taper off the buprenorphine completely. It is quite evident from the study that there was no considerable advantage to any of the three treatments. All three treatments involved randomized drug testing of the subjects. Participants in all three treatments tested positive for cocaine and other illegal substances at about the same rate. This seems to indicate that not only were the treatments not effective for treatment of opioid addiction; they were ineffective in the treatment of substance abuse as a whole. Considering the seeming failure of the three treatments, none should be used in a clinical setting.
Brief buprenorphine detoxification is defined as using buprenorphine to rapidly detoxify a subject who is opioid dependent. A study done in 2008 examined “the feasibility of pre-outpatient detox vacation as a treatment for prescription opioid abusers” (Sigmon et. al., 2008). 15 adults characterized as being dependent on prescription opioids took part in the study. They were administered a two week buprenorphine taper with the end goal being abstinence. Following the two-week taper, subjects participated in 10 additional weeks of therapy from a master’s level therapist. The research showed this was much more effective than both long-term inpatient and long-term outpatient treatment. Drug testing was administered throughout the treatment to determine if subjects had relapsed on opioids or if they were using other illicit drugs. The research showed that 91.7% of subjects were clean after two weeks and were completely tapered off the buprenorphine (2008). 31.2% of subjects were completely clean after the entire 12 weeks (2008).
While there was a significant drop-off of subjects remaining sober after the initial taper, the results still outdo long-term buprenorphine treatment. While it is almost certainly true that if these same subjects had been followed up with one year later, the 31.2% number would have dropped off more, it is still significant that the short-term results showed buprenorphine detox to be so effective. A comparison of the long and short term studies seems to indicate no advantage whatsoever to long-term buprenorphine treatments. The studies also seemed to indicate that brief buprenorphine detoxification is a good way to begin therapy considering 91.7% of subjects were able to quite the use of opioids. Considering this, perhaps brief buprenorphine detoxification is a good way to begin a therapy which transitions into a more successful long term approach after detoxification is complete. In other words, using buprenorphine to handle the initial detoxification, followed by a more effective long-term treatment, may be a good way to treat subjects diagnosed with an opioid use disorder.
Another study done in 2012 compared the use of buprenorphine alone, with the use of buprenorphine combined with short-term counseling. The research showed that there was no significant difference in the rates of sobriety for patients receiving only buprenorphine and those receiving buprenorphine combined with short-term therapy (Fiellin, 2012). This seems to correlate what most studies have found; that counseling combined with buprenorphine is not effective as long as the buprenorphine is not tapered and stopped before treatment is complete. Perhaps, considering the effectiveness of short-term detoxification with buprenorphine, a longer-term counseling approach may be more effective if followed by complete detoxification.
One popular method of long term self help treatment in the United States today is the 12 steps method of Narcotics Anonymous. 12-steps programs work from what is known as the disease model of addiction. Treatments utilizing the 12-steps are practiced primarily by Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous. The 12-step method used by these self-help type groups is perhaps the most widely used treatment philosophy for the treatment opioid addiction in the United States today. “The model has a number of important therapeutic elements, including social support enhancement through group attendance, strategies for coping with dependence, and promoting the development of spirituality” (Emmelkamp & Vedel 2006 pg.104). 12-step based treatments operate in both group and individual settings. Individually, a sponsor is utilized to help guide the addict through the 12-step process. Sponsors are usually chosen by the individual from the group setting and the sponsor is almost always also in recovery. The 12-step method is by far the most utilized in in-patient treatment facilities. Addicted subjects usually begin the 12-step process in treatment and then continue after their release from the program. Public 12-step meetings are easy to find in most American communities. The 12-step method is actually considered a faith-based approach to treatment although, there is no specific god or religious faith advocated over another. The 12thstep states, “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.” (AA Big Book, 2001 pg.59, 60). This spiritual awakening is based on submission to “the God of their own understanding.”
While the 12-step approach is the most widely used in the United States today for the treatment of opioid dependence, there is little empirically supported evidence that supports this method over others. “Despite decades of dominance of approaches based on 12-step principles, there have been no rigorously controlled research design comparing 12-step treatment outcomes to no-treatment controls, and a recent review found no gains in outcomes for 12-step interventions over alternative interventions” (Miller, 2007, p. 568). A study done in the State of Virginia showed the success of 12-step programs, at 0%-15% (2007). This is profound considering the success rate of an opioid dependent person achieving sobriety with no treatment at all is 0%-15% (2007). Miller (2007) gives some interesting insight into the 12-step method; “the result that treatment programs infused with 12-step principles appear at best ineffective, and possibly harmful as interventions based on the counter-therapeutic nature of key elements of the 12-step approach” (2007, p. 573).
The research shows that the 12-step method is not very effective. This is perhaps due to its bases in the disease model of addiction. The disease model theorizes that addiction is an actual physiological disease (Schenker, 2009). The theory surmises that the diseased person has an allergy to intoxicating substances, which causes them to react in an abnormal fashion leading to addiction in many cases. In other words, the disease model theorizes that when most people take an intoxicating substance, they will not develop an addiction. The diseased person on the other hand, has an allergy, which causes addiction if an intoxicating substance in ingested. One major problem with this is that it takes personal responsibility away from the addicted person. Since it is a disease, it is not the fault of the addicted individual. Since addiction is not the individual’s fault, neither is repeated relapse. A common phrase used by participants in 12-step programs is; “it is not me who relapsed, it was my disease.” Further precipitating the problem is the theory that the disease in incurable and all the addicted individual can hope for is a daily reprieve.
A study comparing the effectiveness of 12-step based treatment with a pharmacotherapeutic approach was done recently. The opioid agonist methadone was used. Methadone is similar to buprenorphine in its use as an opioid used to treat opioid dependent individuals. The study was done on 600 subjects over a period of 240 days. Interestingly, there was not a significant difference in the recidivism rate between the two treatments. The research showed an 86.1% recidivism rate for the methadone treated subjects and a 74.8% recidivism rate for 12-step participants (Khodabandeh, et al., 2012). Considering these are the two most widely used treatments in America today, these results are not promising.
Growing in prevalence today is the Christ Centered method of treatment. This section will review the treatments described in the previous sections of this paper by applying a biblical worldview to them. Recommendations will also be made which integrate current treatments with a Christ Centered approach. Biblical evidences will be used to support any recommendations made.
In Paul’s letter to the church in Galatia, he expounds on some extraordinary truths, which are highly applicable to the treatment of those diagnosed with an opioid use disorder. When listing what Paul labeled “the lusts of the flesh,” he wrote; “Now the works of the flesh are evident: sexual immorality, impurity, sensuality, idolatry, sorcery, enmity, strife, jealousy, fits of anger, rivalries, dissensions, divisions, envy, drunkenness, orgies, and things like these. I warn you, as I warned you before, that those who do such things will not inherit the kingdom of God” (Galatians 5:19-21, ESV). Drunkenness is clearly labeled here and is not called a disease. What is not as clear in the English language is Paul’s inclusion of intoxicating substances other than alcohol. The word translated sorcery in verse 20 comes from the Greek word pharmakia. It is from this Greek word that the English word pharmacy is derived. Most bible scholars agree that Paul is referring to an intoxicating substance other than alcohol. What is interesting for the purposes of this paper is that opium was one of the only intoxicating substances other than alcohol in the first century when the letter to the Galatians was written. It is certainly likely that Paul was, in part, describing opioid abuse.
Opioids have a very dangerous property that other drugs do not have at near the level. They are physically habit forming. No other drug causes as severe withdrawal symptoms as do opioids (Reece, 2012). For this reason, many people who have never been addicted to other substances become addicted to opioids. Many times this is due to the individual taking opioids for legitimate purposes and then becoming physically dependent. The DSM-5 criteria for the diagnosis of an opioid use disorder only require the manifestation of two of eleven criterions. Two of these include withdrawal and tolerance. There are many who have developed tolerance and who have experienced withdrawal due to taking opioids for legitimate purposes. An argument can be made that these people do not have a disease, but rather have become physically dependent on a substance which is extremely habit forming. Since these people have never had a substance abuse problem, and only became dependent due to legitimate circumstances, the use of pharmacotherapies may be more effective than with those who have more severe addictive issues.
As is evident from the research analyzed in this paper, the two most common forms of opioid dependence treatments are limited in their effectiveness. While there are no empirically supported studies analyzing the effectiveness of Christ Centered treatment programs, there is anecdotal evidence. The author of this research paper will offer such evidence based on five years of experience in the treatment of opioid use disorders using Christ Centered Treatments. The use of both pharmacotherapies and 12-steps can be far more successful if they are used in connection with psychological assessment followed by long term inpatient treatment utilizing Christ Centered methods. In regards to the 12-step approach, it is most effective when the disease piece is removed and the “God of your understanding” is replaced with Christ.
As the research shows, buprenorphine is effective when used in a brief detoxification therapy of two weeks. Buprenorphine is a narcotic and does give narcotic effects if abused. The use of buprenorphine to treat opioid use disorders can become sinful if not done correctly. Specifically, when practitioners prescribe buprenorphine long term, they are simply enabling their patients by swapping one narcotic for another. As mentioned ad nauseum, the research shows buprenorphine is best used for brief detoxification. For implementation of a proper buprenorphine treatment protocol, ideally, an individual could enter a Christ Centered program where buprenorphine is used to rapidly detox the individual. They would then enter an intensive inpatient program where psychological assessment, followed by Christ Centered counseling would occur over a 12-18 month period. The risk of relapse would be almost zero immediately following detox considering the individual would transition straight from detox into inpatient treatment. Psychological assessments such as the Taylor Johnson Temperament Analysis T-JA (2007) are helpful at determining exactly where to start with counseling and can be helpful when determining scripture to be used in counseling. To review, the foundations of treatment are: detox using brief buprenorphine therapy, immediate transition into 12-18 month inpatient treatment which utilizes psychological assessment followed by Christ Centered treatment.
While there is growing evidence that some people may indeed be born with a higher propensity to addiction than others, this does not make it a disease. Every person is tempted to sin throughout his or her lifetime. Some may be more tempted by homosexuality than others, some may be tempted by dishonesty more than others, some may be tempted by gluttony more than others, and some may be tempted by intoxicating substances more than others. The existence of temptation is prevalent in all mankind, and not all mankind faces the same temptations with the same severity. The point is, God makes no distinction; it is still sinful to participate even though a person experiences temptation at a greater level. There is no therapy that addresses this problem except Christ Centered therapy. Actually, to call sin a disease and therefore admonish the act of committing the sin is sinful in itself, making the 12-steps method as they exist predominantly sinful. Also, considering the 12-step method is predicated on submitting to a “god of your understanding” it can be blasphemous. “I am the way the truth and the life, no one comes to the father except through me” (John 14:6). Submitting to any God other than the true God who is Jesus is sin. As mentioned, there is a Christ Centered 12-steps which is very good. Actually, the 12 steps are biblical principles and the 12-step method started as a Christian organization. It changed in the 1970s. The phrase “god of your understanding was added at that time.
While it is beyond the scope of this research paper to go examine specific Christ Centered counseling techniques for the treatment of opioid use disorders, a general synopsis describes the foundation. Christ Centered counseling addresses reasons why individuals self medicate, with the goal being replacing the need to self medicate with a more fulfilling life. This life is wholly possible through a relationship with Christ. Therefore, Christ Centered counseling is used to teach the truths of God’s word a how to live as His word commands. This begins with salvation and continues with in depth study focused primarily on relational issues. Relationship with Christ is the foundation. This is most effective when done long term in an in-patient setting where temptations are limited. “Now unto Him who is able to do immeasurably more than all we can ask or imagine according to the power that is at work within us” (Ephesians 3:20).
Conclusion and Future Study
There has been far too little research done on the effectiveness of Christ Centered methods for the treatment of substance use disorders. Inversely, there are numerous studies on both pharmacotherapeuticapproaches along with psychotherapeutic approaches. Perhaps the most prevalent in the United States today is the use of the 12-step method. Considering the research examined in this paper, all that is being studied are treatments that do not work. Thankfully, because of schools like Liberty University and Regent University are training practitioners in integrative methods. Hopefully, this will lead to some real research being done on Christ Centered approaches.
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