Opioid agonist therapy and other drugs
Opioid agonist therapy and pain relief
Thirty to 40 per cent of opioid agonist therapy (OAT) clients suffer from chronic pain. Unrelieved pain can lead to illicit drug use or to misuse of prescription pain medication. Unrelieved pain can also affect your quality of life.
Methadone and buprenorphine can provide effective pain relief, but when they are used for pain, the dosage is different from the dosage used to treat opioid addiction. Also, the pain-relieving effects of methadone and buprenorphine last for a shorter time than the maintenance effects. If pain relief is an issue, and you are able to take home carries, your doctor may prescribe that your dose be divided and taken throughout the day. You may also wish to seek out an assessment by a pain and addiction specialist, who may offer recommendations to your OAT provider to treat your pain more effectively.
Acute pain in OAT clients is sometimes under-medicated because medical staff may assume that the methadone or buprenorphine you take provides pain relief. The truth is, once you are on a stable dose of OAT, you may be tolerant to its pain-relieving effects. This means that if you are in pain, you need pain medication just as much as anyone else in a similar situation.
For example, if you have a headache, menstrual cramps or any other low-level pain, you should get relief with a normal dose of Aspirin or Tylenol without codeine. If you require surgery or are in an accident, you should continue to take your normal dose of methadone or buprenorphine, and receive pain medication for the same length of time as anyone else in a similar condition. In some cases, if you are tolerant to the pain-relieving effects of methadone or buprenorphine, you may also be tolerant to the pain-relieving effects of other opioids. Some clients run into trouble with this because the medical staff who are treating them may suspect they are complaining of pain in order to get more drugs to get high.
If you are booked for surgery or dental work, ask your OAT doctor to provide you with a letter that says you are on OAT and how that affects your needs for pain relief. An even better option is to ask the doctor or dentist who is treating you to talk to your OAT doctor.
When you are struggling to overcome opioid addiction, you may question whether or not you want or need to take medication for pain relief. Some people may fear that even taking an Aspirin might lead them back into taking other drugs. Others may feel that their history of opioid use makes it even more difficult for them to cope with pain. If pain is a problem for you, talk to your doctor.
Ontario launched a central system to monitor prescriptions for opioids and certain other drugs in 2012. When filling a prescription for opioid drugs, you may now be asked to show ID. This allows the pharmacist to be aware of other prescriptions for opioids that have been filled for you at other pharmacies. The system is aimed at making the prescribing and dispensing of opioids safer and more secure.
Mixing opioid agonist therapy and other drugs
Methadone and buprenorphine are potent drugs, and can interact with other drugs to have undesirable or dangerous effects or that can affect the effectiveness of OAT. Your doctor knows not to prescribe drugs that will interact or interfere with OAT, but it’s up to you to know the potential impact of any recreational drugs you might take.
Dangerous combinations are described in the sections below.
Mixing methadone or buprenorphine with alcohol or benzodiazepines (e.g., Ativan, Xanax, Restoril, Valium, clonazepam) can kill you. The danger is particularly high when you first start treatment. Most OAT-related deaths involve alcohol and other drugs, and occur early in treatment.
Alcohol, benzodiazepines, methadone and buprenorphine are all central nervous system (CNS) depressants. If you take too much of any CNS depressant, it slows down your breathing, which can lead to heart failure and even death.
When you mix CNS depressants together, they intensify each other’s effects. This means they can make you feel more drunk or stoned than you might expect. It also means that the effect on your breathing is intensified. Combining these drugs is extremely dangerous.
If you show up at your clinic or pharmacy, and it’s clear that you’ve been drinking or using other drugs, you won’t be given your methadone or buprenorphine dose until your doctor has determined that it is safe. Some pharmacists might ask you to do a breathalyzer test if they suspect you’ve been drinking. It’s their job to medicate you safely. They’re on your side.
Alcohol or benzodiazepines can impair your judgment. When your judgment is impaired, it’s easier to get into a situation where you might think you can use your drug of choice “just one more time,” or, just as serious, you might think the person who’s offering it to you is a friend who’s doing you a favour. If you want to keep control of your actions, and protect yourself from people you can’t trust, make it easier for yourself: Stay sober.
Alcohol can also speed up the metabolism of opioids in your body. This means that the methadone or buprenorphine will wear off quicker, and you might end up feeling sick before it’s time to get your next dose.
IS THERE A SAFE LEVEL OF DRINKING?
If you want to drink, this is a question you should ask your doctor. Whether or not it’s safe for you to have a drink or two now and then depends on a number of factors. For example, anyone who is hepatitis C positive should avoid drinking altogether because of the stress alcohol puts on the liver. Another consideration is how alcohol might interact with any other medications you might be taking besides methadone or buprenorphine.
Even though alcohol is everywhere and it’s cheap and it’s legal, when you’re on OAT, drinking can cause more problems than it’s worth.
As we’ve mentioned earlier, methadone and buprenorphine can block the high of other opioid drugs. That means that if you’re on OAT and, for example, you take some heroin, codeine, fentanyl, Dilaudid or Percocet, you may not get the desired effect. What you could get is an overdose, especially if you are taking methadone.
The one thing that surprises me you don’t hear: If you’re on a stable dose of methadone, you cannot get high off opiates. You can die; you just can’t get stoned. I have friends who stay on methadone for just that reason, even when they are secure in their sobriety, just in the off chance they have one of those days, they know they can’t use.
Glen, 59 | Methadone, 15 years
DRUGS THAT WILL CAUSE WITHDRAWAL
Certain drugs can reverse the effects of opioids and cause withdrawal. Naloxone is an example of one that could save your life if you were to overdose. Another one is naltrexone. It can be used by people who have stopped using opioids to prevent them from getting high if they use again. Naltrexone can also be used by people with alcohol addiction to help reduce the urge or desire to drink.
If you are taking buprenorphine, you are likely taking Suboxone, which is a combination of buprenorphine and naloxone. When Suboxone is placed under the tongue, the body does not absorb the naloxone. However, if you were to inject Suboxone, the naloxone would take effect, and you could experience withdrawal.
Buprenorphine itself can cause withdrawal if used by someone who uses opioids regularly, including methadone.
Some medications can cause the body to break down methadone more quickly and can cause withdrawal if the dose is not adjusted.
Too many people who get on OAT start using cocaine or crack. Cocaine is highly addictive and has the potential to make people anxious and paranoid, even violent and deluded. Taking it will give you a whole new set of problems, and there are no drug therapies like OAT to help you to deal with a cocaine addiction.
When I first began methadone, in some ways I felt the same opioid effect as when I was using—I did not have cravings. Over time the satisfaction diminished and I was vulnerable to seeking a replacement drug. Methadone is not a cure for drug cravings other than for opioid cravings. I was not prepared for this return desire to get high and I thought I would be fine to take cocaine and crack, etc. People should be prepared for this change in desire that may occur over time and take steps to protect their environment so they are not too vulnerable to being with people who use other drugs.
Sean W., 36 | Methadone, 15 years
Once I went on methadone, I found cocaine and I fell in love with that. I haven’t stuck a needle in my arm in years, but I just can’t get rid of the pipe.
Brett, 50 | Methadone, 1 year
People often focus on the benefits of marijuana, saying it helps them to relax, improves their appetite or reduces their pain, and dismiss the risks. While marijuana can have positive effects for some people, it’s important to recognize that it can also distort your senses and thinking. In some people, marijuana can reduce motivation or trigger anxiety, paranoia and depression. If you use marijuana, talk to your doctor or counsellor about whether it might cause problems for you.
OTHER DRUGS / VITAMINS / HERBAL REMEDIES
Some other drugs can be dangerous if taken in combination with methadone or buprenorphine. Others may alter or interfere with the effectiveness of OAT. This includes drugs that are prescribed or that you get from a pharmacy or health food store. To be safe, and to be sure you’re comfortable, let your pharmacist and physician know about all of the other drugs, vitamins and herbal remedies you take.
OPIOID AGONIST THERAPY, ANTIDEPRESSANTS AND OTHER PSYCHIATRIC MEDICATIONS
Mental health issues, such as depression, anxiety or posttraumatic stress, may make people more vulnerable to developing an addiction to opioids. If you were taking antidepressants or other psychiatric drugs to treat your mental health symptoms before starting OAT, your doctor will check for potential interactions and change your medication if needed. It’s important to take any prescribed medications as directed, and to tell your doctor about any symptoms you experience or any unwanted effects that might be caused by the medications. Some people find that OAT helps to relieve mental health symptoms.
If you have a history of injection drug use, everybody’s hoping that once you’re on OAT, you’ll never touch another needle in your life. Sometimes, though, it takes longer to get clear of drugs than it does to begin agonist therapy. Always avoid injecting, but if you do, please follow this advice:
Always use a new needle. Even cleaning with bleach may not protect you from becoming infected with hepatitis C (HCV). Many people who inject drugs are infected with HCV. Sharing needles, spoons and filters, and anything else used around injection can pass on blood containing the HCV or HIV virus and put you at risk of becoming infected or of passing an infection on to someone else. Needles are only meant to be used once. After that they are dull and could damage your veins. Dispose of used needles safely so no one gets sick or hurt. Needles are available through needle exchanges, pharmacies, some clinics and public health departments.