Opiates are powerful painkillers. They also are highly addictive and commonly abused, said Dr. Ken Warren, a board-certified family practice physician.

Concerned about the number of patients he was seeing with an opiate addiction, Dr. Warren has been participating in a Drug Enforcement Administration program for the past five years to treat those who have become addicted.

Opiates, the most prescribed medications in this country, include OxyContin, morphine, codeine, Fentanyl, Dilaudid, Lorcet and Hydrocodone, the most popular prescription. Sadly, said Dr. Warren, the numbers of people becoming addicted to these highly effective painkillers has increased and crosses all economic boundaries. Programs to address these issues are increasing, and some are having very positive results.
"These medications are very effective for pain control, and well-meaning physicians want to keep their patients comfortable," said Dr. Warren.

"The opiates are so addictive that soon your body signals it wants more, even if you don't need more. This leads to patients feeling good when they have an opiate and feeling bad when they do not. This results in their going back to the doctor for more medication. If the doctor is not alert to the patient's needs and situation, more prescriptions may be written and even stronger medications given. And the vicious cycle of addiction is started."

Addiction can happen in a short time

Opiates have a short life span in the body. After absorbing acute painkillers every four hours for two to three weeks, the body is in an addicted state. Chronic use can lead to tolerance of the medication, characterized by a patient's need to consume more and more of the drug to achieve the same pain relief.
Withdrawing from opiates is often extremely difficult and intense for those who have become dependent on them. Many are unable to kick the addiction without medical intervention. Withdrawal symptoms can include nausea, vomiting, chills, insomnia, muscle and bone pain, tremors, slowed breathing, constipation and headaches.

"Once hooked on opiates, this terrible addiction becomes an all-consuming problem, and the patient will do anything to keep the medications coming," said Dr. Warren.

"Some will even doctor shop looking for more prescriptions. When I see these patients in the office, they are often taking 20 to 30 pills a day.

They know they are addicted, but are unable to quit. Often, they have tried to stop, but the symptoms of withdrawals — muscle and belly cramps, chills, diarrhea and aching all over — are just too much for them to tolerate. They feel horrible and will do anything to stop the feeling."

Programs such as those established by the government to treat heroin or hydrocodone addicts use another drug, methadone, to help patients reduce their reliance on the more addictive drug.

Methadone treatment not the best solution

"Methadone is very sedating and the person is basically drugged all of the time," said Dr. Warren. "These programs do not really concentrate on getting the patients off drugs. They are not really a drug treatment program, but more of a maintenance program as the patient often will be on the methadone forever or until they go to another drug."

Warren wanted to start a program that had the goal of weaning the addict off all additive drugs completely. His program uses Suboxone, a medication that was initially only allowed in institutions and through programs much like the methadone clinics.

"The Drug Enforcement Agency (DEA) realized the need for a clinic that had no stigma attached to it, so they approved Suboxone for use in an office setting," said Warren, who is one of only two medical doctors in Jackson offering the program.

To be able to prescribe Suboxone, a physician must acquire a DEA number and additional certification from the DEA. A new program is limited to carrying 25 active patients for the first two years. After that, the number of active patients can increase to 100. The DEA monitors and inspects the Suboxone programs regularly.
The purpose of Suboxone is twofold. First, it helps the patient get through the withdrawal phase relatively painlessly. Secondly, it helps to curb the cravings for the opiate. This craving can be more troublesome than the withdrawal.

Hard to ignore addictive craving

"It is difficult for addicts to get clean because of the hold the craving can have on them," said Dr. Warren. "Those cravings can be triggered by many things. Suboxone helps curb craving. With time and counseling to alter addictive behavioral patterns, the dependent person can be helped to control his or her problem."
Patients wanting to be a part of this type of program must first register with the National Alliance of Advocates for Buprenorphine at www.naabt.org. The patient is asked to provide basic information, including age, employment status and addictions.

Registration is anonymous, but it does show the patient the physicians in the area who are a part of this program. The NAABT site relates the patient's information to the physician's office via computer. Patients are treated in the office the same as a regular patient. Not all insurance plans cover this program, and some cover it with time limits.

The medication can average $11-$15 a day, with the generic form costing less. The typical addicted person obtaining his or her drugs off the street will be spending approximately $200 per day to satisfy their habit.

"When I receive a patient's information, I evaluate it to see if I can help. If so, I send the patient an email," said Dr. Warren. "The patient then sets up an appointment for the Suboxone program. The initial appointment takes about an hour. We look at the patient's history and support system and educate the patient about the drug. We also talk to the patient about how the program works and what is expected while he or she receives treatment. Acceptance into the program requires the addict to be actively involved in the recovery."

Induction into the program requires about a half a day in the office with the patient being given small incremental doses of Suboxone to determine the correct dosage amount. The patient returns the following day to fine tune his or her dosage needs and again in 10 days. If all is going well, the patient returns each month.

A drug test at every visit

"At every visit, a drug test is administered," said Dr. Warren. "It is a very accurate, chain-of-custody compliant test, and my rule is, if you fail it, you are dismissed. I am very strict about this, and patients must make a conscious decision to comply with these requirements."

"Failing the drug test includes finding anything in the test that is not prescribed with a valid prescription and that we have discussed is appropriate for them to take, finding anything in the test that we haven't discussed, or not finding what should be there. If a person is prescribed Suboxone, for example, and none is in his or her system, then it is a failure because the person is not following protocol and is likely diverting the drug."

Patients remain on the program for an average of 12 months. They start with a maintenance phase for six months, and they receive a stable dose of medication every day while in this phase of the program. After six months, they start on the tapering phase of the program.

"During their monthly visits, I spend a lot of time counseling the patients." said Dr. Warren, who says he is the therapist in the majority of cases but does use local psychologists when appropriate.

Although it is not a requirement, Dr. Warren strongly suggests patients attend Narcotics Anonymous and become involved in a church.

The program's success rate is difficult to determine because an addict is never cured. He or she is forever a recovering addicted person.

"You hope they stay clean and are able to function daily and without medication." said Dr. Warren. "How well they do depends on their degree of commitment to the program and their desire to control their addiction."