Opioid Use Disorder and the Many Paths to Recovery

By:  Jessica Nevill, LMHC, Clinical Director, WIN Recovery

Opioid use has been the focus of a great deal of national attention recently, with good reason. According to the National Behavioral Council, Americans consume 80% of the opioid prescriptions given worldwide. According to the Centers for Disease Control and Prevention, an average of 41 people die each day in the United States from overdoses on prescription pain killers. As a result, America is now in an opioid crisis. There is a growing number of individuals dying daily from overdose as well as increased criminal activity and increased HIV/AIDS rates.

Opioids have been prescribed in the United States to help individuals who are experiencing pain. These medications are effective at blocking the pain and providing relief. This is done by impacting the “reward pathway” which allows the person using the opioid to experience pleasure and an overall state of well-being. However, when used repeatedly over long periods of time, the person can build a tolerance to the medication which does not allow them to experience the same levels of well-being that they experienced before. This results in individuals taking more and more of the medication to get the same desired results.

So how does this result in an opioid crisis? When individuals need more and more medication to reach desired amounts of relief, they often use medication faster than prescribed. This results in their bodies becoming dependent, and can lead individuals to seek alternative ways of acquiring pain medicine. The Substance Abuse and Mental Health Services Administration (SAMHSA) has reported that over half of individuals who abused pain killers received them for free or from a relative. Once these individuals are no longer willing or able to provide this medication, individuals often turn to alternative methods such as buying medication illegally or beginning the use of heroin which is also an opioid. Once individuals begin using illegal methods to maintain an opioid dependence they are then at higher risks for HIV and AIDS, incarceration, separation from family, and loss of employment.

Opioid Treatment Programs (OTPs) are working to tackle the opioid crisis by providing individuals with medication such as methadone, buprenorphine, and naltrexone to help them discontinue the use of illicit substances. Methadone activates the same parts of the brain as other opioids. Buprenorphine activates the same parts of the brain, but without the rewarding effects. Naltrexone blocks the part of the brain that opioids activate and removes rewarding effects. Research shows that methadone and buprenorphine, when prescribed by a physician and closely monitored, are the most effective treatment methods for opioid use disorder.  Methadone is considered the “gold standard” of treatment, especially for pregnant woman who are addicted to opioids. This, along with behavioral health services such as individual and group counseling, help individuals gain the skills needed to maintain success in their lives.

WIN Recovery is a State licensed opioid treatment program located in Terre Haute and Vincennes Indiana.  The office provides comprehensive treatment to adults 18 years of age and older suffering from opioid use disorder.  Through medication assisted treatment and behavioral health services individuals are able to Regain Something Lost to addiction. The facility is open 7 days a week, and walk-in assessments are available from 6 a.m. to 10:30 a.m., Monday through Friday. Fees are based on the provision of service, with Medicaid accepted and no referral necessary.

For more information, call (833) 232-0215, visit our location at 1433 Willow St, Vincennes, IN, or go to www.winrecovery.org.

WIN Recovery: Regain Something Lost

Hamilton Center, Inc., based in Terre Haute, IN, and serving multiple counties throughout central and west central Indiana, is committed to supporting the State of Indiana in responding to the opioid crisis which has been growing in recent years. As a community mental health center, Hamilton Center, Inc. has been treating individuals with substance use disorders and a variety of other behavioral health issues for over 49 years.

WIN Recovery is the first Opioid Treatment Program (OTP) of its kind certified by the State of Indiana in Knox County.  The clinic will provide daily Methadone administration and behavioral health counseling and case management to provide comprehensive medication assisted substance abuse treatment

I. The problem:

  • Substance abuse costs our nation over $740 billion annually
  • Opioid overdose continues to be a major public health problem in the United States.  There were 67,367 lethal drug overdoses in 2018 – most were opioid related. 
  • Drug overdose is the leading cause of accidental death in the United States.  Over the past several years, Indiana has seen a record number of heroin overdose deaths.
  • The rate of opioid-related emergency department visits to Indiana hospitals increased 32% between 2009 – 2014
  • Indiana suffered 1,211 deaths from drug overdoses in 2019 (18.7 per 100,000)
  • In Vigo County, 10 deaths were attributed to opioid overdose in 2019. 

II. Who is at risk?

  • Individuals using heroin are not the only individuals at risk.  Anyone who uses opioids for long-term management of chronic cancer or non-cancer pain is at risk for opioid overdose, as are persons who use heroin.  Those who use prescription pain killers are 40x more likely to develop an addiction to heroin.  Nearly all addicted individuals believe at the outset that they can stop using drugs on their own and most try to stop without treatment.  Because of the drug-induced changes in brain functioning, many individuals have behavioral consequences, even long after they may have stopped using drugs, including continued impulsiveness to use drugs despite consequences.

III. Medication Assisted Treatment (MAT):

  • Medication-Assisted Treatment (MAT) is opioid addiction treatment that includes medication administration such as Methadone coupled with other behavioral health services such as individual and group counseling, case management and other support services as appropriate. 
  • Medication is prescribed and administered under monitored, controlled conditions and is safe and effective for treatment for opioid addictions when used as directed.
  • Methadone treatment provides patients with medication, health, social and rehabilitation services that relieve withdrawal symptoms, reduce cravings and allow normalization of the body’s function. 
  • Methadone has been used for over 50 years world-wide and is the gold standard of opioid treatment as it is most effective and least expensive.
  • Methadone represents a community return on investment as the average cost of treatment is $5,500 annually compared to $25,000 annually for incarceration.
  • Methadone treatment programs are associated with a decrease in criminality, promotion of patient employability and education and connects patients with other medical and mental health care. In addition, the relationship between intravenous drug use, needle sharing, hepatitis and HIV/AIDS exposure is well documented. Methadone treatment is the most effective intervention for reducing the spread of HIV/AIDS and hepatitis – consistent with strong public health initiatives.

IV. WIN Recovery:

  • Hamilton Center, Inc., Vigo County, opened its first clinic in Terre Haute in May 2018.  In November 2018 the organization received a second license from the State of Indiana to establish a clinic in Knox County.   
  • WIN Recovery Knox County is currently open and accepting patients 18 years of age or older.
  • The program is certified by the State of Indiana, SAMHSA and accredited as appropriate. 
  • In addition to medication assisted treatment, services will include individual and group counseling, case management and other behavioral support services as appropriate.
  • Hamilton Center, Inc. is partnering with Sagamore Medical Recovery Services, LLC which was formed in 2016 by Christian A. Shaw, MD, PhD and his partners.  Dr. Shaw is a leader in the field and has worked to develop the most successful, innovative and respected methadone based opioid treatment program in New Mexico.  Sagamore is providing the medical component of the clinic; Hamilton Center is providing the behavioral healthcare which will include individual therapy, group therapy and case management.
  • Hamilton Center is working with several community partners to integrate services within the Knox County community. This includes collaborating with the community mental health center, the hospital and physican practices, criminal justice, law enforcement amoung others.
  • The office is open from 6:00 am – 2:30 pm with new patients being seen from 6:00 am – 10:30 am.  The clinic is open everyday including holidays and weekend.

For additional information call 833-232-0215 or 812-494-2215.  Appointments can be made, however walk ins are welcome.

History and Effectiveness of Methadone Maintenance Treatment

Methadone treatment provides the patient who is opioid dependent with medication, health, social, and rehabilitation services that relieve withdrawal symptoms, reduce physiological cravings, and allow normalization of the body’s functions. Methadone treatment has been available for over 30 years and has been confirmed effective for opioid dependence in numerous scientific studies.

Moreover, in 1997, the U.S. Department of Health and Human Services’ National Institutes of Health (NIH) Consensus Panel found the following concerning methadone treatment: “Of the various treatments available, methadone maintenance treatment, combined with attention to medical, psychiatric and socioeconomic issues, as well as drug counseling, has the highest probability of being effective.”

Methadone treatment programs are staffed by professionals with medical, clinical, and administrative expertise. Patients receive medication from a health professional. Patients routinely meet with a primary counselor (social worker, caseworker, or certified substance abuse counselor), attend clinic groups, and access medical and social services.

Methadone’s effectiveness, and the absence of any serious, long-term side effects from using it, have been demonstrated in numerous studies conducted over the past 30 years. Among the most commonly cited outcomes are:

  • Consumption of all illicit drugs declines to less than 40 percent of pretreatment levels during the first year and eventually reaches 15 percent of pre-treatment levels for patients who remain in treatment 2 years or more.
  • Crime is reduced substantially: For example, in the most detailed study of treatment outcomes to date, during the first 4 months of treatment, crime decreased from 237 crime days per year per 100 addicted persons during an average year of their addiction to 69 crime days per year per 100 patients, a reduction of more than 70 percent. This number declined further to only 14.5 crime days per year for patients in treatment 6 years or more.
  • Fewer individuals become infected with HIV: A study by Metzger, et al, 1993, showed that over a 3-year period, 5 percent of patients in methadone treatment became HIV positive (over and above those already positive at admission), while among a cohort of out-of-treatment addicts in the same neighborhood, 26 percent became HIV-positive (over and above those already positive at baseline).
  • Individual functioning improves, as evidenced in improved family and other social relation­ ships, increased employment, improved parenting, etc., according to the Substance Abuse and Mental Health Services Administrations Center for Substance Abuse Treatment, 1994, and Lowinson, et al, 1992.

Source: U.S. Department of Health and Human Services, Medication Assisted Treatment for the 21st Century

Heroine vs. Methadone vs. Suboxone

TOPICHEROINMETHADONEBUPRENORPHINE (Suboxone)
Onset of actionA few seconds30 minutes30-40 minutes
Duration of action4-6 hours24-36 hoursAbout 24-48 hours
Route of administrationInjection, snorting, smokingOralSublingual
Frequency of administrationSeveral times a dayDaily or more frequently as neededEvery day or every other day
Effective doseEver increasingBlocking dose usually 80-120mg2-32mg
ToleranceIncreasing toleranceTolerance is stableTolerance is stable
Euphoric effectsEuphoria for up to 2 hoursNo euphoria when stabilizedNo euphoria when stabilized
Overdose potentialHigh and increasingRare (potential is mixed with other depressants)Very rare
Overall safetyPotentially lethalVery safeOverall good. Suboxone injection will cause serious withdrawal symptoms in dependent person. Not recommended for pregnancy and caution with liver disease
WithdrawalWithin 3-4 hours after last doseWithin 24-36 hours after last doseWithin 36-48 hours after last dose
CravingRecurringEliminated with adequate doseCraving may not be totally eliminated due to ceiling effect
Pregnancy/NursingGrave risk for mother and fetusSafe during pregnancyNot indicated/study underway
Experience of pain and emotionsBluntedNormal and full range of emotionsNormal pain but opioid analgesics may not be effective – may need to switch to methadone. Full range of emotions
MoodConstant mood swingsNormalNormal
Reaction time and intellectual functioningImpairedReaction time normal. Intellectual functioning unimpaired on stable doseReaction time presumed to be normal like methadone. FDA cautions driving/operating machinery in the beginning of treatment
HIV & Hepatitis C transmissionHigh rate with needle use and unprotected sexReduced/eliminatedReduced/eliminated
Immune system for HIV positive personsRapid progression to AIDSProgression slowedProgression presumed same as methadone – data not available
Immune/endocrine system functioningImpairedNormalized during treatmentPresumed normalized. Data not available
Stress ResponseSuppressedNormalized during treatmentNormalized during treatment
Criminal activityHigh levelReduced/eliminatedReduced/eliminated
Community impactDestructing impact. High crime, high death rate, transmission of diseaseContributed to public safety, low mortality, increased healthContributed to public safety, low mortality, increased health
Reproduced from 2003 Medication Assisted Treatment for the 21st Century: Community Education Kit, SAMHSA

Frequently Asked Questions

Does methadone treatment impair mental function?

Methadone treatment has no adverse effects on intelligence, mental capability or employability. Methadone treated patients are comparable to non-patients in reaction time, in ability to learn, focus and make complex judgements. Methadone treated patients do well in a wide array of vocational endeavors, including professional positions, service occupations and skilled, technical and support jobs.

How is success in methadone and other pharmacotherapy treatments defined?

The primary goals are to help addicts cease heroin use and lead more stable, productive lives. But, as knowledge about heroin addiction and effective treatment practices has grown, so too have the objectives of most methadone treatment programs, which also aim to:

  • Decrease criminality and reduce the numbers of substance abusers entering the criminal justice system.
  • Assist patients in addressing multiple substance abuse (including crack/cocaine addiction and alcoholism).
  • Assure treatment for general health matters, especially those related to drug use, such as HIV/ AIDS, tuberculosis and hepatitis
  • Promote patient employability and educational development.
  • Identify and treat mental health problems and alleviate homelessness, family substance abuse and child and family dysfunction.

Why do drug-addicted persons keep using drugs?

Nearly all addicted individuals believe at the outset that they can stop using drugs on their own and most try to stop without treatment. Although some people are successful, many attempts result in failure to achieve long-term abstinence. Research has shown that long-term drug abuse results in changes in the brain that persist long after a person stops using drugs. These drug-induced changes in brain function can have many behavioral consequences including an inability to exert control over the impulse to use drugs despite adverse consequences – the defining characteristic of addiction.

How effective is drug addiction treatment?

In addition to stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain in treatment stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning. For example, methadone treatment has been shown to increase participation in behavioral therapy and decrease both drug use and criminal behavior. However, individual treatment outcomes depend on the extent and nature of the patient’s problems, the appropriateness of treatment, and related services used to address those problems and the quality of interaction between the patient and his or her treatment providers.

How long does drug addiction treatment usually last?

Individuals progress through drug addiction treatment at various rates, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommended for maintaining positive outcomes. For methadone maintenance, 12 months is considered the minimum and some opioid addicted individuals continue to benefit from methadone maintenance for many years.

How do other mental disorders coexisting with drug addiction affect drug addiction treatment?

Drug addiction is a disease of the brain that frequently occurs with other mental disorders. In fact, as many as 6 in 10 people with an illicit substance use disorder also suffer from another mental illness; and rates are similar for users of licit drugs-i.e., tobacco and alcohol. For these individuals, one condition becomes more difficult to treat successfully as an additional condition is intertwined.

Is the use of a medication like methadone simply replacing one drug addiction with another?

No – as used in maintenance treatment, methadone is not a heroin/opioid substitute. It is prescribed or administered under monitored, controlled conditions and is safe and effective for treating opioid addiction when used as directed.

Source: NIDA, “Principles of Drug Addiction Treatment”

WIN Recovery, Knox County Now Open

Hamilton Center Inc.’s Certified Opioid Treatment Program to serve adults with opioid use disorder

June 1, 2020 Vincennes IN- Hamilton Center, Inc., a certified Indiana community mental health center, announced the opening of its newest certified opioid treatment program, WIN Recovery at 1433 Willow St., Vincennes, IN.  This clinic is one of two opioid treatment programs operated by Hamilton Center Inc. with a third scheduled to open in the fall in Hendricks county.

The office is open from 6:00 am – 2:30 pm.  New patients are welcome to walk in without an appointment between 6:00 a.m. – 10:30 a.m. or can call toll free 833-232-0215 or 812-494-2215 to make an appointment. The clinic is open 7 days a week including weekend and holidays.

The facility, which is 5032 square feet, includes three medication dosing stations, separate drug screening rooms, physical examination room, and rooms for individual and group counseling.   Black and white photography of local landmarks adorn the walls which were secured through assistance from the Knox County Public Library and Terre Haute photographer Wayne Jordan.   

In November, 2018 Hamilton Center received a license to open the Knox county program.  The clinic will provide comprehensive treatment for adults 18 years of age and older who are struggling with addiction to heroin or other opioids such as prescription pain medication.  The program provides daily medication (Methadone) coupled with individual and group therapy and case management services to treat each individual’s unique needs.

Whether opioids are prescribed by a physician or acquired illegally, with continued use and misuse, they can cause serious changes to the brain and body.  People often hesitate to begin the recovery process due to fear of the physical symptoms associated with withdrawal, or because they doubt recovery is even possible.

Methadone is a medication administered daily under monitored, controlled conditions. It has been utilized for years with a great deal of research determining its safety and effectiveness. Once patients begin taking methadone at appropriate levels, withdrawal is avoided, cravings are minimized and physical and mental stabilization occurs. “That is when the real recovery begins,” said Jessica Nevill, LMHC, WIN Recovery’s Clinical Director. 

“The combination of medication and behavioral health interventions is the most effective in combating this disease,” said DJ Rhodes, Chief of Opioid Treatment at Hamilton Center Inc.  “Opioid Use Disorder is a disease; treatment works and recovery is absolutely possible,” he added.

“We are so grateful to the Knox county community for welcoming this clinic to the area”, said Melvin L. Burks, CEO of Hamilton Center Inc.  “There is a solid understanding of the benefits of medication assisted treatment and because of that many people in this community will benefit,” he added.  

Hamilton Center, Inc. is a regional behavioral health system in Central and West Central Indiana. The organization provides service regionally to 13,000 clients annually.  For additional information on Hamilton Center Inc., call 800-742-0787. For additional information on WIN Recovery call (833) 232-0215.

To learn more please visit www.winrecovery.org.

Grief from Loss During Uncertain Times

By: Emily Grimwood, MSW, LSW, Therapist, Hamilton Center, Inc.

            Spring is a time for celebration and new beginnings. The flowers bloom, the sun begins to shine again, and families prepare for graduations, vacations, and the completion of a school year full of hard work – a moment of validation for both children and parents. Unfortunately, COVID-19 has altered those experiences for many, and instead, this spring has been filled with very different experiences for families around the world.

            This season, families are facing the grief of unmet expectations. While many associate grief with death; grief is a necessary experience for any loss, including the loss of the spring for which we had hoped. Every person grieves loss differently. There is no “normal” way to grieve, and it is okay to accept that the world we live in right now is not “normal.” We must let go of our expectations and accept the many things that are out of our control.

            Our children have had to relearn how to participate in their education. The traditional standards of achievement and engagement in the educational process have change rapidly causing added stress for everyone involved. To support the mental health of children, it is important to validate the challenges they currently face in their learning and to remain mindful of the challenges they face in attempting to succeed in a setting they did not plan for, and likely did not want.

            Adolescents, specifically those with plans to graduate in the spring, are likely experiencing loss in a unique way. Events that teenagers have spent years planning for and looking forward to have been ripped away from them. Events like graduation and prom, senior day, or even that final goodbye with friends on separate journeys into adulthood are all lost- replaced with a seemingly cruel in-home detention. These losses are significant and these youths are valid in any anger or disappointment they may feel as a result. Let them feel these feelings. Let them communicate them. Do not try to fix it for them; the fact is, that is not something that is possible. These milestones cannot be replaced. Allow teenagers to grieve them.

            In these trying times, children and adolescents aren’t the only ones deserving of adjusted expectations; parents, you deserve it too. That structure and those rules you put so much effort into maintaining no longer apply; at least not absolutely. It is important to focus on surviving and caring for your mental health alongside that of your children’s. Taking care of yourself is a crucial part of taking care of them. You cannot support your children when you are burnt out from putting everything into them and nothing into yourself. It is less important in these times to rigidly restrict screen time or make sure your children are getting perfect grades – it just is. So, concentrate on happiness and know that you are a good parent in doing so.

            Finally, it is okay to not be okay. It is okay to have challenges with the current state of the world, to have fear, to feel unsure; it is also okay to experience joy even in these difficult times. Celebrate small victories and take whatever opportunities you can to help yourself and your family grasp onto light in the darkness amidst all of the uncertainty. Together we can survive this and continue moving forward in our lives.

Hamilton Center, Inc. is a regional behavioral health system in Central and West Central Indiana with corporate offices located in Terre Haute, IN. Services are provided to children, youth and adults, with specialized programs for expectant mothers, infants, and people who may be struggling with stress, life changes, or relationship issues as well as more serious problems such as depression, anxiety disorders, and serious mental illnesses.

For information on Hamilton Center Services call (800) 742-0787.