I don't specialize in addiction treatment, but occasionally I do have patients who tell me they've been overusing prescription narcotics. For example, I once treated a woman for depression who was dependent on Vicodin that was originally prescribed after surgery by her OB/GYN. Over the years she had tried quitting on her own, unsuccessfully. Her PCP had continued to prescribe it as long as she didn't increase the dose. She asked me for help, and I referred her to a local addiction treatment program, but she declined to go because she didn't view herself as an "addict." I didn't feel qualified to manage a detox, so I continued to encourage her to see an addiction specialist. Eventually, she left my practice because of a move.
In retrospect, I should have tried to treat her myself. The fact is, I just didn't feel comfortable managing an outpatient opioid detox.
I wish I had read Dr. Michael Weaver's article in the upcoming issue of The Carlat Addiction Treatment Report, which explains, in very practical terms, how to treat patients with different levels of severity of opiate abuse.
Here's what he recommends for a patient like the one I treated. Try a gradual outpatient taper. The simplest option is to taper using the medication your patient is already taking.
"For example," he writes, "if a patient has become dependent on taking 8 to 10 Vicodin per day, you might reduce the dose by a half pill every few days initially, speed up the taper to a full pill per unit time, and then slow it back down to a half or a quarter pill at the end." Such a taper may well take over a month to complete.
A more involved option is to first switch the patient to a long-acting opioid, such as methadone. I know, you probably think methadone is used only at registered facilities where patients line up every morning for their fix. Actually, any physician can prescribe methadone to help patients reduce narcotic use if it was initially prescribed for pain.
Here's a sample reference table covering methadone and other medications used to treat opioid addiction:
View full-size PDF table
Dr. Weaver explains the nitty gritty of this technique in the full article appearing in The Carlat Addiction Treatment Report. He also covers how to do a Suboxone (buprenorphine/naloxone) induction (it's easier than you think). And he holds you by the hand as you learn the pros and cons of the many formulations of buprenorphine available.
If you aren't subscribed to The Carlat Addiction Treatment Report, I urge you to give it a try. You'll have instant access to all of the articles we've written about opioids.
Not only will you learn the latest unbiased information about addiction treatment, but you'll earn CMEs while you're doing it. All with our usual 100% money back guarantee if the newsletter does not turn out to be extremely useful for your practice.
Daniel Carlat, MD
Publisher The Carlat Addiction Treatment Report