Elizabeth Brico, Author at Workit Health

Debunking Two Common Myths About Buprenorphine

Buprenorphine (the active ingredient in Suboxone and Subutex) is a highly effective partial-opioid agonist used to treat the cravings and withdrawal associated with opioid addiction.

It is easy to take, and starts working quickly; a person in acute withdrawal can expect to begin feeling better within an hour or so of placing it under their tongue. It is also easier to dispense in the United States than methadone, which had been the gold standard for treating opioid use disorder for decades. Providers currently have to take a special course in order to be able to prescribe buprenorphine, but once they have that prescribing waiver, they can write scripts for their patients in the same manner as most other medications. That means most buprenorphine patients do not have to pick up their medication daily, and can induct with very little interruption to other important routines like work and school.

As effective and convenient as taking buprenorphine is, there are still two big, persistent myths about the medication cycling through drug using communities.

You Can Go Into Withdrawal If You Only Take Buprenorphine

One of the rules about beginning buprenorphine treatment is that patients must wait until they are in acute withdrawal before taking their first dose. This is really important because if someone with an opioid dependence takes buprenorphine too soon, they will go into precipitated withdrawal.

“Any buprenorphine formulation will cause precipitated withdrawal if taken too soon.

Precipitated withdrawal is an aggressive state of acute withdrawal. It happens when the buprenorphine—which binds powerfully to the brain’s opioid receptors—knocks out all of the other opioids, but can’t fill the receptors as well because it only binds to those receptors partially. Basically, the withdrawals can be described as smashing the impact of a full three or more days of withdrawal into just a couple hours. And—because buprenorphine also blocks the effects of other opioids, it might be impossible to stop the withdrawals with another dose of a conventional opioid. It is extremely dangerous to try to overcome the blocking effect by taking higher doses. Precipitated withdrawal can cause severe vomiting and diarrhea, and might require a visit to the emergency room.

Any buprenorphine formulation will cause precipitated withdrawal if taken too soon. Unfortunately, there’s a pesky, persistent rumor that only some formulations lead to precipitated withdrawal. That’s because some people believe that the naloxone added to some formulations, like Suboxone, is the ingredient that blocks the effects of other opioid and causes withdrawal. Not so. Buprenorphine itself binds to the opioid receptors and blocks the effects of other opioids. So buprenorphine-only formulations, like Subutex, will cause precipitated withdrawal if taken too soon. Just like buprenorphine/naloxone formulations, buprenorphine-only versions will also block or diminish the effects of other opioids.

Naloxone is an effective short-term opioid blocker. Used correctly, it will knock opioids out of those receptors and block other opioids from taking effect for about half an hour or so. But it doesn’t work orally. That means if a person takes Suboxone under the tongue as directed, the naloxone isn’t actually doing anything. Small amounts of naloxone are added to some buprenorphine formulations to deter misuse.

“Another common misconception is that a person who uses an opioid while stabilized on buprenorphine will have to go into withdrawal before taking more buprenorphine. That’s not the true!

Naloxone, which is also the drug used to reverse an opioid overdose, is effective when injected or snorted. So if someone were to attempt to inject Suboxone or another buprenorphine/naloxone formulation, the naloxone would block the effects of the buprenorphine. It would feel similar to injecting plain water. If someone were to inject enough of it, it could even cause withdrawal. But that’s the only way the naloxone gets activated. Taken sublingually, it’s not doing anything; the buprenorphine is doing all the work.

You Don’t Have to Wait to go Into Withdrawal Before Dosing If You Relapse

Another common misconception is that a person who uses an opioid while stabilized on buprenorphine will have to go into withdrawal before taking more buprenorphine. That’s not the true! But wait—didn’t I just write up there that buprenorphine is doing all the work, and will cause precipitated withdrawal? Yep, that’s true. But you still don’t have to go into withdrawal if you’re already taking it.

“If you or someone you know has lapsed on an opioid while taking buprenorphine, it’s important to know that you can go right back to your treatment regimen.

Explaining this can be a bit tricky. In fact, one of my former treatment providers had such a hard time understanding what I was saying that they thought I was trying to teach patients how to overdose—but that was on them for not fully understanding the mechanism of buprenorphine. To be clear: I’m not recommending that anybody relapse while on buprenorphine. Using a short-acting opioid while on buprenorphine can be really dangerous. Buprenorphine blocks the euphoric effects of opioids, but it’s still possible to experience respiratory depression and overdose. Some users want to get high so badly that they will take higher and higher doses of a full opioid in an attempt to overcome the blocking effects of the buprenorphine. In fact, that user was once me. I took a much larger hit of heroin because I knew my buprenorphine would block my normal dose. The next thing I remember is my husband on the phone with a 911 operator, as I slowly regained consciousness because of the naloxone he’d given me. I came very close to dying that day. If there’d been no Narcan in the apartment, I might not be writing this today. No way am I recommending that anybody relapse while on buprenorphine.

That being said, lapses happen. If you or someone you know has lapsed on an opioid while taking buprenorphine, it’s important to know that you can go right back to your treatment regimen. This only applies, however, if there is still buprenorphine in their system. Buprenorphine is a long acting drug, so it lasts about 48-72 hours. If it’s still filling up those receptors and helping to keep a person from experiencing withdrawal, then taking another dose will not result in precipitated withdrawal—even if there are other opioids in the person’s system. This applies even if enough opioids were taken to overcome the blocking effect. Buprenorphine will only clear out the other opioid. It won’t displace itself. So whatever effect that other opioid is having will go away, but the buprenorphine will continue to work. If it’s still in your system and helping to keep you out of withdrawal, you can go right back to taking it. If someone goes on a three or four day binge without taking buprenorphine during that time, then they will probably need to go into withdrawal before re-starting the bupe.

Elizabeth Brico is a freelance writer with an MFA in Writing & Poetics from Naropa University. Her blog, Betty’s Battleground, was recently ranked by Feedspot as one of the top 75 PTSD blogs. She is also a regular contributing writer for HealthyPlace’s trauma blog. Her work has appeared on Vice, Vox, Stat News, The Fix, and others. When she isn’t working, she can usually be found reading, writing, or watching speculative fiction.

How Illicit Fentanyl Affects Buprenorphine Induction

The landscape of black market opioids has seen some pretty major changes over the years.

An influx of illegally manufactured fentanyl has infiltrated the heroin market, and has even been found in other street drugs like cocaine and pressed pills, leading to an uptick in overdose deaths that have been described by some as an “epidemic” or “crisis.” When produced for pharmaceutical purposes, fentanyl is a powerful, fast-acting opioid administered for acute breakthrough pain that can’t be managed with less potent opioids like morphine. It is sometimes used during child labor, for example, or during hospice care for terminally ill patients. But the formulations showing up in street drugs are not pharmaceutical fentanyl, meaning you can’t count on them to have the same properties as the fentanyl that’s prescribed to patients.

““There are literally hundreds of [fentanyl analogues], most of them we still don’t know anything about.””

— William E. Fantegrossi

William E. Fantegrossi is an associate professor of pharmacology and toxicology at the University of Arkansas for Medical Sciences College of Medicine who has done contract work for the DEA testing new drugs being found on the streets. He spoke with me while researching a story for the Columbia Journalism Review about the myth that fentanyl can endanger law enforcement personnel through skin contact (spoiler: it can’t). He has seen new formulations showing up in street supplies, some with radically different properties than conventional, pharmaceutical fentanyl.

“There are literally hundreds of [fentanyl analogues], most of them we still don’t know anything about,” Fantegrossi said during our interview. He explained that street chemists make changes to the fentanyl formulation so that it can have a variety of effects including making it feel stronger at lower doses, or making the drug “last three times as long.” A lot of attention has been given to the danger these variations pose to users, who don’t necessary know what they’re getting each time they use a new bag. But one factor that has not gotten as much media attention is what role this could play in buprenorphine treatment.

“Buprenorphine is still a highly effective treatment for addiction to illicit fentanyl. But because you and your doctor may not know the exact properties or half-life of the drugs you’ve been taking, it’s very important to pay close attention to your withdrawal symptoms. ”

Buprenorphine works by filling opioid receptors similarly to drugs like heroin or fentanyl. But it doesn’t fit them as perfectly. That means it won’t produce the same sense of euphoria or pain relief. Because it has a higher affinity for those receptors, however, it will stop other opioids from taking effect if someone tries to use, for example, heroin after taking buprenorphine. If someone tries to use buprenorphine after taking heroin, however the bupe will knock the heroin out of the receptor. In that scenario, a user with a dependency on heroin or other opioids will go into a state of precipitated withdrawal. Essentially, his body will be suddenly forced to experience the full force of the withdrawal period all at once. It is a grueling and potentially life threatening experience. It’s also the reason why physicians who are starting patients on buprenorphine make sure to wait a specific period of time before administering that full dose. For short acting opioids like heroin or pharmaceutical fentanyl, 12 to 24 hours opioid-free is usually long enough to wait before starting buprenorphine. But what happens when street supplies contain illicit fentanyl formulations with unknown effects, including unknown durations?

When to administer a first dose of buprenorphine is not just decided by the length of time since the patient last used an opioid. Medical staff—or patients taking their first dose at home—should also use the severity of withdrawal as a guideline. This can be somewhat difficult, since every person is different. While some people experience vomiting and diarrhea at the height of their opioid withdrawal, others find their worst symptoms are chills and agitation. So it is important for patients to be honest about what their withdrawals typically look like—and for providers to trust what their patients report.

“It’s important to make sure you are fully in withdrawal before starting buprenorphine. Whether you’re inducting at home or in a medical setting, make sure you don’t take that first dose just because it feels like enough time should have passed.”

The Clinical Opioid Withdrawal Scale (COWS) is a checklist of common withdrawal symptoms used to determine the objective severity of a patient’s withdrawal. Objective means of determining patient discomfort—such as pupil dilation, inability to sit still, and excessive sweating—can help providers gauge whether or not it’s safe to start the first dose of buprenorphine, regardless of how much time has elapsed since their last use of an opioid. It is also important for patients to accurately measure and report less visible withdrawal symptoms, like anxiety, cravings, and stomach pains. Even if it’s been 24 hours since a patient’s last drug use, if she doesn’t know her “heroin” was actually (or only) heroin, she could end up experiencing precipitated withdrawal because there was still some longer acting fentanyl in her system. If you’re self-determining when to start your first dose of buprenorphine, it’s really important to make sure you’re scoring as being in mid to high range withdrawal, which is usually a six or higher on the COWS scale. Taking that first dose too early could come with serious consequences—and might even land you in the emergency department.

Buprenorphine is still a highly effective treatment for addiction to illicit fentanyl. But because you and your doctor may not know the exact properties or half-life of the drugs you’ve been taking, it’s very important to pay close attention to your withdrawal symptoms. Waiting for that first dose of buprenorphine is tough, especially when your cravings are calling. But it’s important to make sure you are fully in withdrawal before starting buprenorphine. Whether you’re inducting at home or in a medical setting, make sure you don’t take that first dose just because it feels like enough time should have passed. Waiting is tough, but avoiding precipitated withdrawal is absolutely worth it!

Traveling While In Medication Assisted Recovery

If you’re new to agonist medication for opioid use disorder, you might be wondering how (or if) you can travel while being prescribed Suboxone or Methadone. This blog will give you some helpful information about traveling while in a MAT program.

The term agonist medication means an opioid-based medicine used to treat the cravings, withdrawal, and brain changes associated with opioid addiction. The two most commonly prescribed types of opioid agonist drugs prescribed for opioid use disorder are methadone and buprenorphine. Wondering whether or not you can travel, especially for extended periods, is a valid question, especially if your provider requires you to come in daily for dosing, or will only prescribe you a week’s worth at a time, as is common with these types of medications. Rules, regulations, and typical practice differs by medication. Here are some of the facts when it comes to traveling with methadone and buprenorphine:

Buprenorphine

Buprenorphine is generally less restrictive than methadone because federal guidelines allow providers to prescribe patients the drug for longer periods the way they can with other medicines. However, licensed Opioid Treatment Providers (OTPs)–what we often call “methadone clinics”–must dispense medication through their facility, which includes buprenorphine if they choose to prescribe it.

Each substance use disorder program or physician can impose their own regulations on how much buprenorphine they prescribe at a time. Intensive outpatient programs(IoP), for example, often require daily participation in groups and therapy, and therefore also dispense the medication daily. Another common practice is for physicians to prescribe the medication to new patients for one week at a time, extending that as the patient stabilizes in treatment. So how do these practices play out when a patient needs to travel?

If you are traveling for only a few days, you should not have an issue. Even if your provider requires daily dosing, they will typically have no problem giving you a couple days worth of take-homes if you are stabilized on the medication and doing well. It is probably a good idea to avoid planning trips, when possible, during the induction phase of your treatment. Many providers want to be able to check in with patients during the first few days or weeks on the medication, to ensure that patients don’t have any issues like precipitated withdrawal, side-effects or allergic reactions, and to get the patient on an effective dose. Some programs might require you to prove that you’re traveling by showing a copy of your plane tickets or other travel itinerary. Putting the stigmatizing elements of such a practice aside for the moment, getting buprenorphine take-homes should be a relatively easy process.

In all cases, give your provider as much notice as possible when traveling, especially if you are traveling out of state. This will allow your provider to work with you when it comes to prescribing enough medication to last for the full length of your trip. Some issues might arise regarding insurance. For example, it might not be possible to get an early refill covered. This could happen if you change the dates on which you receive prescriptions to accommodate your trip. If you’re planning a trip that exceeds a month, your insurance might be unwilling to cover more than a month’s worth of medication at a time. Some providers, including WorkIt, will not transfer buprenorphine prescriptions to a different state. For this reason it is important to plan ahead with your provider, and in some cases, also with your insurance.

Methadone

Traveling with methadone can be a bit trickier, both because of actual federal guidelines and also due to plan ol’ stigma. Because methadone is a highly regulated and powerful full opioid agonist, some practitioners are hyper-vigilant about deterring misuse or diversion. It is essential for patients on methadone to plan ahead with their providers.

It is not hard for providers to request take-homes for patients. They have to fill out a request for a federal exception, and that’s usually it. Regardless, some programs might have their own policies in place that can make it more difficult to get enough take-homes to cover a full trip. Methadone patients must typically “earn” their regular take-homes, accruing days off from clinic dosing as their time of abstinence (or perceived abstinence) increases. For newer patients, who have none or only a few take-homes, some providers might be hesitant to prescribe take-homes for a trip. In these cases, it always helps to provide proof of your travel plans, such as tickets or other travel itinerary. Sometimes, especially with longer trips, programs will still feel unsafe prescribing take-home doses for the entire duration of travel. In these cases, they will instead ask you to partner with another program for guest dosing.

Guest dosing means that you will be going to an opioid treatment provider located at your travel destination to receive your daily dose of methadone. Theoretically, setting up guest dosing should be as a simple as a phone call from your home provider to the guest provider (you will probably be required to provide their contact information to your counselor). Unfortunately, theory and practice can sometimes differ widely. It may take days or even weeks for two programs to connect, especially if they are in different time zones. So make sure to plan ahead as early as possible, and stay on top of your counselor. Don’t assume everything is handled just because you have turned in your travel dates and the necessary contact information; check in with your counselor until you receive verification on both ends that guest dosing is set up.

If you are paying through insurance for your methadone, traveling might mean you will have to cover that cost out-of-pocket. If you’re guest dosing in a different state, your insurance may not cover it. Even if you’re guest dosing in an area your insurance covers, that particular clinic might not accept your insurance. Yes, that applies to Medicaid too. It’s a good idea to find out ahead of time whether or not your insurance will cover your medication while traveling. If it doesn’t, make sure to calculate medication costs into your travel plans. The last thing you want is to go into withdrawal during an important business conference or while out enjoying your vacation.

Flying with Medication

In general, there are a few rules you should always follow if you are using commercial air transportation. These same rules apply to medication for opioid use disorder. The most important is to keep your medication in your carry-on bag or personal item. Don’t pack them away in luggage. If your luggage is lost, then so is your medication. If your luggage is searched and mishandled, causing the meds to fall out or open and spill, that’s that. And while some other types of medication can be easily refilled, not so for opioid based medication—especially methadone and bup
renorphine.

Carry proof of your valid prescription with you as well. Often methadone and buprenorphine bottles come with labels that include your name and prescription details. If want to be extra cautious, however, bring a copy of your prescription, or ask your provider for a note that includes your prescription details, and the name and number of your provider. The reality is that TSA is not looking for drugs—they’re looking for safety threats to the aircraft and passengers. So your medication is unlikely to be of much interest to them. Nonetheless, it’s a good idea to be safe.

Some people receive liquid methadone and have concerns about bringing that onboard an aircraft. TSA does get testy about liquids. But don’t worry. In general, passengers are allowed to bring containers of liquids under 3.4 ounces that can fit into a quart sized, resealable bag. Most methadone prescriptions fit that description—but if yours doesn’t, the TSA blog says that you can bring liquid medication as carry on even if it exceeds 3.4 ounces and does not come in a bag. They advise you to tell the TSA agent about your medication before going through the scanner. The blog also warns that your liquid medication may be subject to additional screening, including asking you to open the container.

Traveling while taking medication for opioid use disorder can be a little extra complicated. Hopefully there will be a day when these medicines are regarded like any other essential medications and that will no longer be the case. But you don’t have to wait for society to change to do some traveling. With a little extra planning ahead, and clear communication with your provider, it is possible to get away from home while on methadone or buprenorphine.

What I Wish I Had Known During My MAT Pregnancies—Part III

In Part III of this series on recovery meds like methadone and buprenorphine during pregnancy, Elizabeth Brico explores emotional and legal issues pregnant women on MAT face.

Welcome to the final installation of my three-part series on WorkIt Health about issues surrounding medication assisted treatment during pregnancy. If you’re reading this, you’re probably pregnant and using methadone or buprenorphine, or thinking about getting on one of these medications to help treat your opioid use disorder. Or maybe you know someone else who is. Either way, I’m glad you’re here, and I hope I help you with some of the questions I had when I was pregnant on MAT. If you haven’t read parts one and two yet, check them out here and here.

Before reading further, you should know that I am not a medical expert. Rather, I am a patient who used methadone and buprenorphine during two separate pregnancies. The information I’m sharing with you is based on my personal experience, and research I’ve conducted on the topic.

In the prior segments, I talked about some of the social and medical issues related to MAT during pregnancy. Topics like stigma, medication side-effects, and neonatal withdrawal. In this final installation, I’ll go over some of the emotional and legal issues you may face.

If You’re Addicted to Opiates, MAT is the Right Choice During Pregnancy

Through both of my pregnancies, but especially while on methadone, I continuously worried about my child’s potential withdrawal. I worried she would be in pain. I worried she would have problems later in life because of the medication or the trauma of the withdrawal. Even now, when my daughter gets really angry, or doesn’t want to listen, or acts cruelly toward her sister, I sometimes wonder if it’s because of the medication I took while pregnant. I have to remind myself that anger is a natural emotion, kids don’t always listen to their parents, and sibling rivalry is pretty common. But there’s still a part of me that wonders. If you’re feeling worried or guilty, I get it.

You’re doing the right thing. Methadone and buprenorphine are the most effective treatments for opioid use disorder (OUD). Don’t just take my word for it—the World Health Organization considers them “essential medications” for treating addiction to opiates. Detoxification during pregnancy is risky. Although newer studies have shown that it’s possible to have a safe prenatal opioid detox under medical supervision, not all of us have the option of a medically supervised detox. And, abstinence (especially during early recovery) significantly increases the chances of relapse, which poses a big risk to your baby. So, if you’re addicted to opiates and you’re taking your meds as prescribed, methadone or buprenorphine are the best and safest choices for both you and baby during pregnancy.

I don’t think any amount of reading will ever prepare you for the experience of seeing your child go through opioid withdrawal. Although not all opioid-exposed infants will experience postnatal withdrawal, many will (see part two in this series for ways to reduce your baby’s chances of withdrawal). Especially if you know what withdrawal feels like—and let’s be real, if you need methadone or buprenorphine, you do—it is absolutely heart wrenching to watch your newborn sweat and squirm in her crib. There’s no way around it: if your baby experiences neonatal abstinence syndrome (NAS), you’re going to hurt.

Which is why you need to keep reminding yourself that you did the right thing. Although your baby’s first days of life are not ideal, he is alive because of you. Getting sober from addictive substances and onto prescribed medication made you able to be the mother that your child needs. It gave him life. As much as it hurts, remind yourself that your child’s pain is temporary, and it’s the result of a courageous and medically sound choice.

I also found that it helped me to be as involved as possible in my daughters’ care. I held them as much as possible, breastfed when I could, and roomed-in when possible. These actions also help reduce the severity of NAS. Not only will you be nurturing the essential mother-child bond; you will also be taking action to help soothe your baby’s symptoms.

Dealing with Child Services

Depending on where you live, you might get a call or visit from your local child services department. Federal law states that mandated reporters, like nurses and doctors, must report drug exposed newborns. This means that if your child experiences NAS, tests positive for opioids, or if you test positive or even just report your medication (which you should for medical purposes), someone from your hospital will probably report you to child services. That sounds really unfair—and in many ways it is—but it’s not necessarily a huge concern.

Depending on the policies where you live, child services might not even contact you. If nobody suspects you of using other substances while in treatment, child services may forgo an investigation. If you do hear from child services, however, it doesn’t mean you’ve done anything wrong. When I had my daughter in King County (Seattle, WA) while I was taking buprenorphine, I never heard from child services. When I had my daughter in Palm Beach County (Lake Worth, FL) while on methadone I did. A social worker came to the hospital. She interviewed me and my husband. She even called my mom, who was all the way in Seattle and had no idea at the time that I was even on methadone. It was extremely intrusive—but that was the worst of it. My urinalysis records all showed that I was compliant with the program, and the case was closed without intervention.

Some people are less fortunate. If your records show you relapsed while pregnant, or if you case worker is just really ignorant about MAT, you could experience pushback. A lot of people say that if you have to deal with child services, you should just put your head down and do what they say. That works for some people, and it’s totally fine to choose to do that. But fighting for your rights is also an option. If you want to go that route, remember to remain respectful. Anything you say—or the way you say it—can and will be used against you. Remain compliant in treatment. Keep up with you and your baby’s postnatal appointments, and take notes of everything your care workers have you do, and when you do it. That’s my advice as a person who’s been in this situation, not as a legal professional. You definitely want to contact a legal professional.

If your case goes before a judge—which means you’re facing temporary or permanent custody termination—you will be assigned a free lawyer (unless you can afford your own). If you’re not facing termination, but you still feel that you’re being mistreated by child services, you’ll probably have to find legal counsel on your own. There are some organizations around the country that help with these types of matters. The National Alliance for Medication Assisted Recovery (NAMA-R) can’t give you legal counsel, but they may be able to refer you to resources. They have chapters across the country, and a lot of wonderfully caring people who work for them. Legal Action Center specifically deals with issues pertaining to parenting and MAT discrimination. They can only provide legal help in certain parts of the United States, but if they can’t help you, they can also provide referrals. Both organizations are run by people who truly care and understand, many of whom have their own addiction histories. If you think your rights have been violated by child services because of your use of methadone or buprenorphine, reach out to them. You deserve to be treated with respect.

Tapering Down

Now that we’ve gotten the emotionally grueling stuff out of the way, let’s talk about a physical issue. Some people decide they only want to be on MAT during the pregnancy but want to come off right after giving birth. I felt this way when I was on methadone. Others want to remain on MAT for a while—that’s what I did with buprenorphine. Whichever category you fall into, you’re probably going to need to taper down. This is because pregnant women typically need higher and sometimes even more frequent doses of methadone or buprenorphine. Once you give birth, your blood volume and weight decrease, plus you no longer have your baby in there taking some of your dose.

When I was on methadone, the difference was immediate and intense. The day after giving birth, I was nodding out and hallucinating from a dose that felt totally normal while I was pregnant. I was even barred from holding my daughter once when the nursing staff thought I was high. Luckily I had my UA records to show I hadn’t relapsed. But I didn’t start to feel normal until I cut my dose in half. Don’t be surprised if your dose is suddenly too strong.

It’s important to listen to your doctor—but also to your body. My clinic wanted me to taper down by 5mg a week. I wanted to taper by 10mg a week because my dose felt so overpowering. In order to do that, however, I would have had to sign a paper stating I was tapering against medical advice. This is a tricky situation, especially when child services is involved. You don’t want to look like you’re doing anything against medical advice, because someone can try to make the argument that you’re misusing your medication. But if you feel your dose is dangerously high, that’s not something you should ignore. My best advice is to insist upon an appointment with the clinic doctor, and tell him your exact concerns. Doctors don’t want their patients overdosing, so if you feel you’re at that point, he has to work with you.

If you’re only tapering to a comfortable dose and not to get off altogether, make sure to listen to your body’s signals. Don’t put yourself into a position where you’re in withdrawal, because raising your dose is a process when you’re no longer pregnant.

Good Luck

Thanks for reading my series on WorkIt Health about medication-assisted treatment and pregnancy. I had a lot of questions and conflicting emotions during my MAT pregnancies. I hope I was able to answer some of yours. Good luck with your parenting journey—and remember: You are good. You are valuable. You are loved. And you’re doing the right thing.

Workit Health offers Suboxone & online therapy in California & Michigan.

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What I Wish I Had Known During My MAT Pregnancy, Part II: Side Effects, NAS, and the NICU

I gave birth to the older of my two daughters while taking methadone to treat addiction to heroin.

By the time I had my second daughter, I had switched to buprenorphine. I’m not a treatment professional, but I am in a unique position to speak about my experiences with medication-assisted treatment (MAT) and pregnancy due to my experiences with the two dominant medications used by pregnant women in recovery.

This is part two in a three-part series about MAT and pregnancy. In part one, I discuss stigma and the likelihood of birthing an infant who experiences neonatal abstinence syndrome (NAS). In part two, I will share some of the side-effects I experienced, and some new research that may help reduce some of those side-effects as well as the risk or severity of NAS.

Side-Effects of Medication-Assisted Treatment During Pregnancy

Methadone

On methadone, the main side-effect I experienced was sleepiness. In the morning, I awoke to a feeling of restlessness that felt like the early signs of withdrawal. About two to three hours after dosing, I’d begin to fall asleep. As I describe in my Vox article about using methadone during pregnancy, “When my dose peaked, about three hours after ingestion, I fell asleep. Sitting at a desk in writing class, knees crossed for meditation group, slumped against the bus window — wherever I was when that medicine hit, I slept.”

Though I’m not the first person to report this side-effect, it may be preventable. According to research by John McCarthy, a doctor who has spent over four decades treating pregnant women using methadone, sleepiness experienced during methadone’s metabolic peak may indicate that the dose is too high, at least at that concentrated dose, even if the woman shows signs of withdrawal in the morning. Many clinics, including mine, treat morning withdrawal during pregnancy by raising the woman’s dose. But according McCarthy’s research, this leads to maternal and fetal sedation a few hours after dosing.

How can those side-effects be reduced? One method is to offer pregnant women split-dosing. Because a woman’s metabolism changes radically during pregnancy, she may need her opiate-assisted treatment to be administered two or more times daily. This allows her medication levels to remain stable, rather than peaking a few hours after dosing and then waning later. Unfortunately, many clinics (including mine) opt to raise a pregnant woman’s single dose instead, resulting in the sleepiness followed by mild withdrawal that I experienced. This is going to come up again later.

Buprenorphine

I experienced fewer intrusive side-effects on buprenorphine than on methadone, but it should also be noted that my dose was significantly lower. Buprenorphine is stronger than methadone in that people require a lower relative dose to benefit from the effects. Even with that in mind, my dose was very low during my pregnancy. When I discovered I was pregnant, I was on the tail end of a buprenorphine taper. I discovered I was pregnant when I was down to .5 mg. It’s possible I could have jumped off and my baby would have been fine, but I decided not to take the risk, especially because I experienced withdrawal when I tried.

I was a bit sleepy during this pregnancy as well, but that happens during pregnancy. The sleepiness was not as pronounced as it was on methadone. I also felt considerably calmer than I did during my previous pregnancy. This can likely be attributed to several factors. First, when I discovered I was pregnant with my first daughter, I was actively using heroin. Those nine months of my pregnancy were also the first nine months of my recovery. That’s always tough.

Finally, a few small studies have discovered that buprenorphine may help alleviate some symptoms of post-traumatic stress disorder (PTSD), which I have. I’ve found that buprenorphine helps relieve some (though definitely not all) of the anxiety and mood swings that result from PTSD. It’s possible that the buprenorphine helped keep my emotions relatively balanced during my pregnancy.

In terms of negative side-effects, I felt slight mental fog, though that is also associated with pregnancy and PTSD. I also experienced some “creative blunting,” meaning that I felt less of an imaginative spark when it came to creative writing. Again, however, it’s difficult to determine whether that was the result of the medication, the pregnancy, trauma, stress, or a combination of these factors. One study found that long-term buprenorphine users experienced flat affect and reduced awareness of positive emotional states.

Reducing the Chances of Neonatal Abstinence Syndrome (NAS)

It is impossible to completely eliminate the chances that your infant will experience NAS. Withdrawal is a very real possibility for infants whose mothers use opioids — prescribed or not— during pregnancy. Weighed against the other possibilities — namely maternal relapse, miscarriage, or birth defects — MAT is still a very good option for pregnant women in recovery from addiction.

Even though you can’t totally eliminate the possibility that your baby will experience NAS, there are ways to reduce the possibility and severity of symptoms. The first thing to remember is what will not reduce the chances: a low dose. Many women, including myself, think that keeping on a low dose of methadone or buprenorphine will ensure her child does not have withdrawals. That is simply not true. Take me, for example: I began on 20mg of methadone, and slowly went up to 60mg. 60mg is a lower dose than many people take, and is even considered by some doctors to be below the threshold for a therapeutic dose. (including Mary Jeanne Kreek, who helped develop methadone treatment for addiction). You already know that I was on a very low dose of buprenorphine. But both of my daughters experienced some withdrawal, and the daughter who was born while I was on methadone experienced fairly significant withdrawal for over a month. This doesn’t, mean, however, that higher doses will stave off withdrawal either, so don’t go and ask your doctor to raise your dose 30 mg without reason.

Staying Out of Withdrawal

Remember when I said that split dosing would come up again? That same research found that the best way to reduce the chances of NAS was to keep the mother out of withdrawal. Which is, of course, part of the purpose of MAT during pregnancy. But the response that my clinic shared with many others around the United States — raising a mother’s single dose when she begins to experience withdrawal — may not be the right one. Offering split dosing (and also raising the dose
when necessary) during pregnancy will keep mothe
r’s medication levels stable, which translates into keeping her out of withdrawal. And in McCarthy’s study, that meant 29% of infants experienced withdrawal, as opposed to 60%-80% during the more common treatment course.

Unfortunately, while some clinics offer split dosing for pregnant patients, many others have strict policies against it. There is no database that details how many clinics offer split dosing, but the fact that this relatively simple practice is not implemented at every clinic presents a significant problem. If you’re pregnant and your clinic or provider won’t offer you split dosing, contact your State Opioid Treatment Authority and advocate for yourself and your child.

No NICU

The Neonatal Intensive Care Unit (NICU) is a hospital ward where infants are sent when they experience a significant health condition that requires medical intervention. Premature infants are sent there, some jaundiced infants, and newborns with other serious health conditions. Many hospitals, including the ones where my daughters were born, also send babies who show symptoms of NAS to the NICU. But experts say that is the wrong thing to do.

If you want to keep your baby from suffering too greatly, keep her near you. Maternal bonding, breastfeeding, and skin-to-skin contact are far better at soothing infants than a dose of morphine or rounds of surveillance in a separate hospital ward. The bright lights and noisy environment in the NICU may also aggravate the baby’s NAS symptoms, causing her to score higher on the symptomatic index staff use to determine her withdrawal levels.

Unfortunately, hospitals dictate infant care. Even if you want to room-in with your child and breastfeed, the hospital staff may not let you. When my first daughter was born, I was forced to pump milk and visit her on a schedule while she stayed in the NICU for over a month. When my second daughter was born, I was more adamant. I was also in a more welcoming hospital. Although she was initially placed in the NICU, I was allowed to breastfeed. I continued to ask for a room with her until I finally got it. And she was home in under two weeks.

The severity of NAS ranges. Some babies experience sneezing, while others have seizures. If your child is on the seizure end of NAS, she may require that extra observation and care provided by the NICU. But if her symptoms are not life-threatening, try your best to advocate that she stay with you instead of the NICU. If that doesn’t happen, don’t blame yourself. Some hospitals are more open to listening than others.

Thank you for reading about my experiences with MAT and pregnancy. If you haven’t read part one yet, you can find it here. For part three, I’d like to answer some of your questions. Have a burning question about MAT and pregnancy that I haven’t answered yet? Leave it in the comments — I will do my best to answer what I can.

Workit Health provides Suboxone & online therapy in California + Michigan

What I Wish I Had Known About Suboxone & Methadone During My Pregnancies

Elizabeth Brico writes about medication-assisted treatment, like buprenorphine and methadone, during pregnancy.

The differences between buprenorphine and methadone

I am in a unique position to write about my experiences with pregnancy and medication-assisted treatment for opioid addiction because I have used both of the mainstream MAT options during two separate pregnancies. I used methadone during the first of these two pregnancies, and buprenorphine during the second. In fact, I also gave birth before ever using opioids, so I even have a “baseline” pregnancy to use as comparison.

Opioid-assisted treatment is a hotly contested subject for patients who are not pregnant. Add in a pregnancy, and people can become downright vicious. Some states even prosecute women who use MAT–usually methadone–while pregnant if their children experience Neonatal Abstinence Syndrome (withdrawal), even though neonatal withdrawal is a very real possibility and not the mother’s fault.

One of the side-effects of the stigma and fear surrounding MAT during pregnancy is that women receive a lot of misinformation. Some of this misinformation even comes from providers, who are either ill-informed themselves, or feel that lying somehow serves the patient’s best interests. I personally do not agree that lying or manipulation ever serves a patient’s best interests, but especially not when pregnancy is concerned. So, I’ve written up this three-part series for WorkIt Health about the things I wish I had known when I was pregnant and on MAT.

“One of the side-effects of the stigma and fear surrounding MAT during pregnancy is that women receive a lot of misinformation. ”

There is more stigma about methadone than buprenorphine

As a whole, there is more stigma when it comes to methadone use than buprenorphine use. This is potentially associated with several different factors. For example, methadone is a full-opioid agonist, whereas buprenorphine is a partial-opioid agonist. This leads many people to believe that methadone is “worse” than buprenorphine, or that it has the potential to gives users a “legal high.”

Methadone is also popularly correlated with low-income people who are treating injection heroin addiction, while buprenorphine is more often considered a drug taken by people who were misusing pharmaceuticals. These stereotypes are ill-informed. Both medications can and are used to treat addiction to street-drugs and prescription drugs—not that the distinction should matter in the first place. Furthermore, many people have to pay high fees for the cost of methadone, making it difficult for low-income patients to access the medication in some areas. Many states that cover methadone through Medicaid also cover buprenorphine, and while some buprenorphine doctors do charge extra fees that aren’t typically associated with methadone, the class divide often presents in a specific area for both medicines, or neither.

Despite the stigma, however, doctors typically advise pregnant women coming straight from an opioid addiction to use methadone. This is partly because induction to buprenorphine requires a brief period of withdrawal, which can cause complications during pregnancy. It’s also simply because methadone has been on the market longer, and there have been more tests demonstrating its relative safety for use during pregnancy. Nonetheless, buprenorphine has also tested safely during pregnancy trials, and if a doctor oversees the brief withdrawal period, a pregnant woman should be able to induct without issue. Basically: if buprenorphine is the medication-assisted treatment you wish to take during pregnancy, you should absolutely have the agency to make that choice.

“If buprenorphine is the medication-assisted treatment you wish to take during pregnancy, you should absolutely have the agency to make that choice.”

Buprenorphine is typically associated with less NAS than methadone

Although Neonatal Abstinence Syndrome (NAS) is a very real possibility with both medications—and it’s also possible for your child to experience no withdrawal from either medication—buprenorphine in general has been shown to produce less severe and prolonged withdrawal symptoms, and less neonatal withdrawals in general.

My experience mirrored the statistics. The daughter I had while using methadone experienced moderate-to-severe withdrawal symptoms for about a month and a half, while the daughter I birthed while using buprenorphine had very mild symptoms for under a week. Of course, stigma and location may also have played a large role in this. I gave birth while on methadone in South Florida. There, my infant was almost immediately placed in the Neonatal Intensive Care Unit, under harsh bright lights and away from her family. I was not allowed to breastfeed her. I couldn’t room with her, and on one occasion was even barred from holding her, even though I had done nothing wrong.

On the other hand, I gave birth to my second daughter in Seattle, Washington while on buprenorphine. There, we were allowed to room-in together during her stay. I was given free access to breastfeeding opportunities—in fact, she only recently weaned at over two years of age. I was never stopped from holding her, and was treated with much more warmth and respect by the hospital staff in Seattle than in South Florida. More and more research is showing that breastfeeding and maternal contact are the best cures for NAS, so the deprivation my child and I experienced in Florida likely affected her withdrawal experience significantly.

“More and more research is showing that breastfeeding and maternal contact are the best cures for NAS.”

Both drugs are different, but both are good options during pregnancy

Buprenorphine and methadone are both different drugs that can be safely used during pregnancy to treat opioid addiction. If you are considering using one, know that both are good choices—but that nobody has the right to bully or pressure you to use one over the other. If you feel the withdrawals necessary for buprenorphine induction are too dangerous for you and you’d rather use methadone, don’t let anyone guilt you for that decision. Likewise, if you don’t feel methadone is right for you, don’t allow doctors to pressure you to choose it over buprenorphine simply because it’s been around longer.

Keep your eyes out for the next post in this series, in which I’ll tackle some ways you can reduce the chances of experiencing medication side-effects and NAS.

What It’s Like to Induct on Buprenorphine.

If you have taken the first steps toward enrolling in a buprenorphine treatment program: congratulations! The first moves toward sobriety are some of the hardest and most courageous to take.

Although you are embarking on a healthier path, you are also letting go of your drug of choice, which was an important player in your life, possibly for years. You might also have to say goodbye to friends who are still using, and stop hanging out in familiar but triggering spots. These changes can be bittersweet, and it’s totally normal to feel a sense of longing for the harmful behaviors and substances that you’re letting go of, even if you genuinely want to recover from opioid addiction. Anyone in recovery from drug addiction has to go through this ritual of dislodging from the past, but when it comes to buprenorphine treatment, there are some particular difficulties you should prepare for.

Buprenorphine Works

First of all, know that buprenorphine works. It is a partial opioid agonist, which means that it is a synthetic opioid which fills the same receptors as the drugs you used to get high, but less perfectly. It won’t get you high and you won’t become addicted to it if you use it as prescribed. It will cause you to have a continued dependency on opioids, but think of it as any other daily dose medication; people taking antidepressants and insulin are also dependent on those medications, but it’s not a big deal if they take them as prescribed and continue to have regular access to their prescription.

Buprenorphine is a highly effective treatment for opioid use disorder. Alongside methadone, another opioid agonist prescribed to treat opioid addiction, buprenorphine is an FDA and World Health Organization approved treatment for addiction to heroin, oxycodone, and other opioids. It has been shown to reduce the risk of death in people who use illegal opioids, and decrease the incidence of HIV infection resulting from IV drug use. It also a highly effective aid in reaching sobriety or reducing chaotic use of illegal opioids.

Induction Tips

Buprenorphine is highly effective, however, some patients might experience discomfort during the beginning phases of treatment, called induction. If you are getting ready to begin buprenorphine pharmacotherapy, your doctor will tell you that you need to wait until you are in a state of opioid withdrawal before taking your first dose. This is important, because buprenorphine will knock other opioids out of your system, but it won’t fill the same neuroreceptors as well. If you are still high from other opioids, taking buprenorphine too soon will put you in a state of sudden, intense withdrawal called precipitated withdrawal. If this happens, know that it will eventually pass, but you might require medical attention if your symptoms are severe.

Because buprenorphine does not fill the receptors as completely as the opioids you were using to get high, you might not feel completely normal for a few days. As your body adjusts to the partial opioid versus the full opioids you were previously taking, you may feel agitated, tired, restless, anxious, or depressed. You might also continue to feel mild symptoms of withdrawal while you and your physician work together to determine your therapeutic dose. This is the dose that will help reduce your physical and psychological cravings for opioids. These symptoms should be manageable, and should not feel as severe as full withdrawal. If they are unmanageable or severe, bring that up with your prescribing doctor.

“The first several months of treatment are difficult no matter what type of recovery course you are taking. ”

During the first week or two of buprenorphine induction, once you have begun to stabilize on your dose, you might feel some euphoria. This could manifest as cloudy thinking, elevated mood, and impaired motor function. Some users enjoy this feeling, while others find it off-putting because they are trying to get stop being high. If this happens to you, know that it is normal, and will pass as you progress through treatment. Once you are fully stabilized on your dose, you will no longer feel any euphoric effects from buprenorphine. If you do enjoy the way that first week or so makes you feel, it’s important to know that buprenorphine has a ceiling effect. This means that after a certain dose, usually between 16-32mg, the drug will not have any added effect. So once you stabilize and stop feeling that euphoria, you can’t take more buprenorphine to get it back.

The first several months of treatment are difficult no matter what type of recovery course you are taking. Mood swings, boredom, cravings, and even recurrences of use are all normal. Don’t get down on yourself if you slip up and end up using your drug of choice early in treatment. But be careful: buprenorphine blocks the effects of other opioids, meaning you are less likely to feel high from your previous dose. Attempting to overcome the blocking effect by using more of your drug of choice, however, is extremely dangerous and can easily lead to overdose.

Recovery is not easy, but it’s worth it. Remember that ups and downs are normal, and that the uncomfortable parts of induction will soon pass.

Kratom: Is it Safe?

Lately there have been concerns about the safety of kratom, a withdrawal aid that has been gaining in popularity. Are these concerns valid?

If you’re in recovery from an opioid use disorder, chances are you’ve heard about kratom. Maybe you’ve even tried it yourself. Kratom has gained popularity in recent years as an alternative to traditional opioids, which some people are using as a withdrawal aid, or simply on its own for relaxation. But lately there have been some concerns that the psychotropic plant, which is native to Southeast Asia, could be dangerous or liable to cause addiction on its own. How valid are these concerns? And does using kratom still count as recovery?

Is Kratom Dangerous?

When ingested, usually orally, kratom activates some of same opioid receptors in the brain as drugs like morphine or heroin, and can share some of the same pain relieving and euphoric effects, but is not itself an opiate. Kratom’s effects are a little different than those of an opiate or a more conventional opioid such as fentanyl or methadone. The analgesic and euphoric effects are typically less pronounced than with the natural opiates and synthetic opioids that people have been using to get high for years. It also has some stimulant effects, and does not cause the same kind of respiratory depression that is often the cause of opioid overdose fatalities. For these reasons, kratom has traditionally been considered a safe substance, relative to other opioids. It is not currently scheduled in the United States, although that may change in the near future.

In April, however, the Centers for Disease Control released a report stating that kratom was responsible for 152 deaths in the United States between 2016 and 2017. News outlets were quick to report these findings. After all, if a legal substance is being touted as safe but quietly killing people, the public should know! But the CDC report merits a closer look. For example, the study looked at 27, 338 overdose deaths, meaning kratom-involved deaths only accounted for .56%. And, of those 152 deaths, only seven came back without other drugs in the system. As the report notes, that negative toxicology doesn’t fully rule out the possibility that other drugs were involved, since drug testing is an imperfect science. In the case of 145 of those kratom-involved deaths, the deceased had consumed other substances, which means the fatal event could have been caused by a negative interaction between kratom and that other substance, for example. Fentanyl and heroin were the additional substances most commonly found in the deceased, and we know that combining opioids is dangerous and can lead to increased respiratory depression, even if overdose with just one of those substances would have been unlikely.

Finally, even if we assume the seven people who only tested positive for kratom had, in fact, only consumed kratom—the report does not specify how they died. That leaves open the possibility that the person had an allergic reaction, or had some other medical condition that left him more vulnerable to the effects of kratom, or opioids in general. Essentially, the media reaction to the CDC report was likely overzealous. That doesn’t mean kratom is safe, but there is not currently any strong data pointing toward it being unsafe, either. As with any substance (peanuts kill some people), caution and attention to one’s own personal reaction is warranted.

Can Kratom Help With Opioid Addiction?

Anecdotally, some people report using kratom to help ease the pain of opioid withdrawal. Of course, because kratom activates those same opioid receptors in similar ways as more conventional opioids, using this plant to ease withdrawal is, in some ways, similar to using a milder opioid to ease withdrawal from a stronger opioid. Eventually, if your plan is to no longer have any kind of opioid dependence, you will have to stop using kratom. At that point, you can expect to experience some withdrawal. But some users report that the withdrawal from kratom is milder. Because kratom doesn’t have the same powerful euphoria as heroin or pills like oxycodone, users may find themselves better able to regulate their use—allowing them to perform a gradual tapering down that would have been considerably more difficult with their drug of choice.

Of course, kratom doesn’t have the large body of research backing its efficacy enjoyed by methadone and buprenorphine. But it is legal and might be easier and cheaper to obtain for some people. So, for those who cannot access methadone and buprenorphine, kratom might serve as an alternative withdrawal aid. As with any substance, it’s up to you to pay attention to your unique reaction to the drug. If you find yourself engaging in compulsive use similar to that of other opioids, then kratom may be psychologically harmful for you. And—if you are not able to abstain from other opioids, be careful mixing in kratom as the combination could be dangerous.

Can I Use CBD In Recovery?

CBD is popping up everywhere from coffee shops to doctor’s offices. But is it safe to use in recovery?

Can I Use CBD In Recovery?

The idea of using marijuana during recovery has sparked a lot of debate. Some people argue that it is an intoxicating substance and therefore has the potential to re-trigger a full blow addiction, or that using marijuana is itself a symptom of a continued addiction. Others say responsible, non-compulsive marijuana use is the total opposite of addiction, and even that it can help them manage some symptoms of opioid use disorder, like withdrawal and cravings. But the introduction of one substance has complicated this argument even further. That substance is cannabidiol, or CBD.

What Is CBD?

Like THC, the ingredient in marijuana responsible for those controversial intoxicating effects, CBD comes from the cannabis plant. But unlike THC, CBD doesn’t get you high. Which means the objection to CBD apparently comes from its source, and not the chemical itself. CBD is also responsible for a lot of the medicinal effects attributed to cannabis. For example, it was recently approved by the FDA to treat seizures and is being sold and marketed under the brand-name Epidiolex.

Although seizures are the only official, marketed use for the drug, many people believe CBD can also help with a host of other medical issues. For example, many people believe their anxiety can be relieved by a CBD regimen, and some studies back this, including anxiety related to post-traumatic stress disorder (PTSD). It’s also thought to be responsible for the pain relieving effects commonly associated with marijuana, in conjunction with THC.

Best of all, it delivers these effects without an accompanying high. CBD is non-intoxicating. That’s because while it does affect the brain—hence its medicinal properties—it does not activate the receptors responsible for the intoxicating effects of THC. Similar to antidepressants or over-the-counter pain relievers, CBD changes the brain enough to diminish pain or anxiety, for example, but not in a way that delivers euphoria.

Is CBD Legal?

Unfortunately, CBD has an unusually complex regulatory status. Technically, it is not legal. It comes from cannabis, which is scheduled by the DEA—and they say that covers all the compounds that come from it, too. But that same plant becomes legal when the THC is bred out of it. At that point, it gets classified as hemp, making it legal under the 2014 Farm Bill for certain people to grow it. The general attitude from the DEA and other law enforcement agencies seems to be that if the CBD comes from hemp, it’s not really legal, but it’s tolerated. That’s why you will see it being sold without issues in stores around the country, regardless of their marijuana laws. When it comes to staying above the law during recovery, you’d have to stay away from CBD to be technically in compliance. But it’s extremely unlikely that you will catch a charge if you do buy a bottle of CBD from your local supplements store or vape shop.

Will CBD Show Up On A Drug Test?

The average urinalysis or other drug test typically tests for THC. CBD is a totally different metabolite and therefore won’t cause a test to pop positive for THC. But because they come from the same plant, some CBD products do contain small amounts of THC. Others intentionally add some THC into the product in order to potentiate the effects, especially those sold in states where recreational or medicinal marijuana is legal. If your CBD comes from a hemp source, it should contain .3% THC or less. And that should not make your test show up on the average test, at least not according to toxicologists I interviewed while covering the topic for Vice. Some users have claimed that the trace amounts of THC built up over time, after using CBD products daily for an extended time, and eventually caused them to come up positive for THC. That’s just anecdotal though—the official state is, currently, CBD products from reputable hemp growers won’t cause issues with your drugs test.

So What Does All This Mean For My Recovery?

Addiction recovery is individual. There will never be a straightforward answer to these kinds of questions, because ultimately it’s up to you. Some people feel that even the use of prescribed anti-depressants is an affront on their recovery, because it means they continue to be reliant on drugs. Most people are less strict, and recognize that we rely on many substances throughout our lives. If your use is not compulsive and continued despite negative consequences, it doesn’t meet the technical criteria for addiction. Because CBD does not produce euphoria, it is unlikely to lead to that type of use. And since it likely doesn’t carry significant negative consequences like a failed drug test or incarceration, you should feel pretty safe using it for anxiety, depression, pain, or another issue you are facing in recovery. But in the end, it’s up to you.

Is It Okay to Smoke Pot on Suboxone?

To puff or pass… Should you smoke weed if you are taking Suboxone?

As more and more states legalize or decriminalize marijuana, people in recovery from opioid addiction are wondering what that means for them. Is it okay to partake if you’re on buprenorphine? Ultimately, only you can answer that question for yourself. The landscape of recovery is immensely various, and what one person considers fine might be another person’s relapse. Unfortunately, because of marijuana’s regulatory status and contentious history in the United States, there is not a lot of scientific data on the topic, either. But there is some. And it points to marijuana use being okay while in recovery—at least, if you say it is for you.

Cannabis and OAT Outcome

A 2018 study published in the Journal of Addiction Medicine found that marijuana use did not negatively affect buprenorphine therapy outcomes. It appeared to have some correlation to a lower dose, but did not affect cravings, opioid use, or duration of treatment. Interestingly, a retrospective study of pregnant buprenorphine-maintained women who used marijuana during the third trimester of pregnancy did not find that the use was associated with significant complications either—except for a slightly heightened risk for requiring pharmacological intervention for neonatal abstinence syndrome. That seems like it would merit further study, especially to rule out bias. Were hospital staff more inclined to medicate infants they knew had been exposed to both buprenorphine and marijuana, for example? But if it were me, I would abstain from marijuana during pregnancy just to be safe. Not pregnant and on bupe? Now that looks to be more of a personal choice, with the emerging science concluding that even if it won’t help, it also won’t hurt.

Cannabis as Treatment

Some physicians now claim that cannabis has therapeutic value for opioid addiction. The state of Pennsylvania has approved the use of medical marijuana for opioid use disorder, and other states are working hard to get OUD added as a medical marijuana qualifying condition. In Philadelphia, Joe Schrank runs a cannabis-based recovery center called High Society. Although he uses an abstinence based model for his own recovery, he acknowledges that some clients aren’t ready to stop experiencing some form of intoxication. For those people, marijuana poses a less harmful and addicting alternative to heroin or other illegally obtained opioids.

“[Cannabis forms] a great therapeutic alliance from the get-go. Like, we’re here with compassion, we’re not here to punish you, we want to make this as comfortable as we possibly can, and the doctor says you can have this [marijuana]. I think it’s better than the message of ‘you’re a drug addict and you’re a piece of shit and you’re going to puke,'” Schrank told me during an interview for an article I wrote for The Fix.

Cannabis to Get Off Buprenorphine

Although many people choose to stay on buprenorphine long-term or for life, some decide to get off the drug after a short period of time. Others (like myself) find themselves unable to continue to pay for the medication, and are therefore forced to taper or discontinue use prematurely. Hopefully everyone who has to come off a stable dose of buprenorphine gets to taper, but whether someone jumps off a high dose or tapers slowly, some withdrawal is to be expected. During that taper or detoxification period, some people find cannabis to be extremely therapeutic. For example, Stephanie Bertrand, who I also interviewed for the article I wrote last year for The Fix, used marijuana to facilitate the heightened anxiety and physical discomfort associated with her buprenorphine taper. She was able to drop by 2mg at a time using cannabis as an aid.

Views on recovery vary. Some people believe that if you’re experiencing intoxication in any form, you are not truly in recovery. Others define it as a healthier way of living; one which can include moderate marijuana or alcohol consumption. How you define your recovery is up to you. I can’t tell you whether it’s okay to use marijuana while also taking buprenorphine or otherwise in recovery from an opioid use disorder; only you can decide that for yourself. If you decide to give it a try, check in with yourself, and watch for signs of addiction. That means compulsive use, like smoking when you don’t really want to or hadn’t planned to, even when doing so will lead to negative consequences.

If you are concerned cannabis is getting in the way of your recovery or your life, there are a variety of screening tools available to help you determine if your use is a problem.

Workit Health operates in a harm reduction mindset. This means that controlled cannabis use that does not impede daily activity and is done in a safe manner will not result in dismissal from our opioid use disorder program. It is important to note that everyone reacts to cannabis differently. Always discuss cannabis use with a healthcare provider. If you find yourself concerned about your cannabis use, please contact your Workit Coach or call us at 855-659-7734.

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