Avance Psychiatry offers outpatient buprenorphine-naloxone maintenance for opioid addiction. The three phases of maintenance are (1) induction, (2) stabilization, and (3) maintenance. All phases are combined with counseling and behavioral treatments and urine toxicology monitoring. Different formulations of buprenorphine-naloxone or buprenorphine (Suboxone®, Subutex®, Bunavail®, Zubsolv®) are used for maintenance.

Induction is the first phase of treatment and involves the patient switching from illicit opioids to buprenorphine. The goal of induction is to find the minimum dose of buprenorphine at which the patient stops use of other opioids and experiences no withdrawal symptoms or cravings. Induction is initiated after a comprehensive medical evaluation that determines whether the patients is a suitable candidate for buprenorphine treatment. The usual duration to complete induction is approximately 1 week and requires multiple office visits. Induction can be performed in the office (more common) or at home (less common). Office based induction involves the patient being given 2-4 mg of buprenorphine at a time and monitored for 2-4 hours in the medical office to evaluate adequacy of dose. Home based induction involves patients provided buprenorphine to take home with clear dosing and monitoring instructions. Induction buprenorphine dose is usually 4-12 mg/day.

Stabilization phase begins after induction is complete and patient is free of withdrawal symptoms and tolerating the buprenorphine well. The goal of stabilization phase is to adjust the dose of buprenorphine to produce desired benefits of opioid receptor blockade and laboratory indices (negative urine toxicology) while minimizing side effects. Engagement in counseling and compliance with treatment are other goals. The duration of stabilization is 4-8 weeks and may involve weekly to biweekly contact with the provider. Stabilization doses of buprenorphine range between 8-24 mg/day.

Maintenance phase of treatment is started after patient is sufficiently stable on buprenorphine and no longer experiences uncontrollable cravings or withdrawal symptoms, has negative urine toxicology and has minimal side effects to buprenorphine. The goal of maintenance is abstinence from illicit drug use, improvement in work and family life and relapse prevention. Counseling is an important aspect of maintenance and patient must demonstrate responsible handling of prescribed buprenorphine. There is no recommended duration of maintenance. It can be relatively short-term (e.g. <12 months) or medium term (1-3 years) or long term (> 3 years) process. Following successful maintenance, decisions to decrease or discontinue buprenorphine are based on a patient’s desires and commitment to becoming medication-free, and on the physician’s confidence that tapering would be successful.

Sublocade® is once a month buprenorphine subcutaneous injection that is approved for treatment of opioid addiction. Sublocade® is appropriate for patients who have been stabilized on Suboxone® or Subutex for at least seven days. Sublocade® is available in two doses a 300 mg dose and 100 mg dose. It is injected subcutaneously (under the skin) in the abdominal region once a month and stays in the system continuously without daily ups or downs for at least 4 weeks. It is beneficial for patients who find taking daily doses of buprenorphine difficult. It can also be helpful for tapering patients off Suboxone®. Avance Psychiatry arranges for assessment, insurance approval, shipment of Sublocade® is from pharmacy to the office and administering the injection in the office. Sublocade® is given as a part of a comprehensive treatment plan that includes counseling and drug screen monitoring.

Buprenorphine-naloxone (Suboxone®) is effective for detoxification from heroin and prescription opioids. Detoxification is a process of medical supervised administration of buprenorphine to ease the discomfort of withdrawal and interrupt craving and drug use. Due to its unique pharmacology, buprenorphine is highly effective and safe in suppressing opioid withdrawal symptoms. Buprenorphine has been used in three ways for withdrawal from opioids: The long period withdrawal (>30 days), usually on an outpatient basis; moderate period withdrawal (>3 days but <30 days), again on an outpatient basis; and short period withdrawal (<3 days), which often is conducted on an inpatient basis. The available evidence shows that long-period buprenorphine detoxification is more effective than moderate- or short-period detoxification but that all forms of detoxification are less effective compared with ongoing maintenance. Avance Psychiatry offers outpatient medical detoxification using buprenorphine-naloxone (Suboxone®) or buprenorphine (Subutex®) or clonidine or lofexidine (Lucemyra®). We have developed standardized short term, medium term, and long term detoxification protocols that include buprenorphine and adjuvant medications to treat opioid withdrawal. It should be emphasized that detoxification is not completion of treatment and individuals should engage in outpatient individual or group counseling and monitoring to facilitate effective transition into ongoing recovery.

Avance Psychiatry provides treatment with opioid antagonists (“blockers”) such as long acting injectable naltrexone (Vivitrol®) or oral naltrexone (Revia®, Depade®) for opioid addiction. Naltrexone is approved to prevent relapse to opioid dependence in patients who have completed detoxification from opioids. It is combined with counseling and monitoring to facilitate recovery. Individuals should be fully abstinent from opioids for 7-10 days confirmed by negative urine toxicology before starting naltrexone to avoid precipitated withdrawal. Naltrexone is an ideal opioid antagonist treatment medication: It is a pure, potent mu antagonist that has minimal side effects. It is neither reinforcing nor addicting and has no potential for abuse or diversion. The blockade by naltrexone is highly effective in eliminating any euphoria by re-exposure to opioids.

Vivitrol® is a long acting intramuscular (IM) injection of naltrexone (380 mg) that is given once a month. It addresses the problems of noncompliance with oral naltrexone. Other advantages of Vivitrol® are bypassing the liver (“first pass metabolism”) and less dose requirements. Opioid medications are ineffective for pain management if patient is on Vivitrol®. As with oral naltrexone, Vivitrol® carries a black box warning for liver injury, although this is very rare. Patients should carry a Vivitrol® alert card to inform physicians in case of emergencies requiring pain management. Naltrexone is most useful for highly motivated patients who desire total abstinence because of external circumstances. Examples are physicians or lawyers in recovery. Other potential target populations are individuals at the experimenting stage of opioid use, or those who are in early stages of their addiction. Avance Psychiatry arranges for assessment, insurance approval, shipment, and intramuscular administration of Vivitrol® in the office for appropriate patients.

Oral naltrexone (Revia®) dose is 50 mg tablet per day and is recommended for highly motivated individuals who desire complete abstinence. Common side effects include nausea and fatigue. There is a black box warning about liver toxicity requiring blood tests to monitor liver enzymes. Non-compliance with oral naltrexone is a common problem limiting its clinical use.

Chronic heavy drinking can cause long-lasting changes in the brain mechanisms that result in the need to drink more to ward off craving and other withdrawal symptoms. Alcohol Use Disorder (AUD) medications that help balance brain chemistry, help reduce cravings, and block the pleasurable effects of alcohol, can free a person to focus on recovery. They can (CSAT TIP49, 2009):

• Lengthen periods of abstinence, which in turn can increase individual coping capacities necessary for long-term recovery;
  Prevent a lapse from becoming a full-blown relapse;
• Allow brain cells to readapt to a normal nonalcoholic state, helping patients think more clearly, have more positive emotional responses, and increase readiness for change;
• Relieve symptoms of protracted withdrawal, and;
• Support the effects of psychosocial treatment and sustains the gains of intervention

FDA-approved medications for alcohol addiction are not addictive and generally have mild side effects, if prescribed and monitored carefully. Since the risk in using them is low, and they can make a difference for a patient who might otherwise relapse, they are an option well worth considering. Avance Psychiatry offers medications such as long-acting injectable naltrexone (Vivitrol®), disulfiram (Antabuse®), oral naltrexone (Revia®), and acamprosate (Campral®) to assist in reducing heavy drinking and achieving abstinence. Individuals are encouraged to attend on-site individual counseling.

Injectable naltrexone (Vivitrol®)

Vivitrol® is the newest FDA approved medication treatment option for alcohol dependence. Vivitrol® is a long-acting, extended release formulation of naltrexone administered as a single 380 mg intramuscular (IM) injection once a month. Studies have shown that when combined with proper psychosocial therapy, Vivitrol® is much more effective than support alone. As with oral naltrexone, Vivitrol® carries a black box warning for liver injury, although this is very rare. Opioid medications are ineffective for pain management if patient is on Vivitrol®. Patients should carry a Vivitrol® card to inform physicians in case of emergencies requiring pain management.  Naltrexone is an opioid antagonist. It binds to opioid receptors, blocking the ability of endogenous opioids released with alcohol consumption to bind and activate the release of dopamine. This reduces the pleasurable effects of alcohol, and can help reduce cravings. Naltrexone does not stop patients from consuming alcohol, nor does it precipitate any physical symptoms when alcohol is consumed while the patient takes naltrexone.

Oral Naltrexone (Revia®)

Oral naltrexone is recommended for highly motivated patients willing to take tablets every day. The dose is 50 mg tablet once a day. Common side effects include nausea and fatigue. There is a black box warning about liver toxicity requiring blood tests to monitor liver enzymes. Non-compliance with oral naltrexone is a common problem limiting its clinical use.

Disulfiram (Antabuse®)

Disulfiram is an aversion medication therapy that blocks the breakdown of alcohol in the liver resulting in a buildup of acetaldehyde and a toxic reaction 5–30 minutes after drinking alcohol. The “disulfiram-alcohol reaction” includes nausea, vomiting, facial flushing, headache, dizziness, sweating, heart palpitations, and blurred vision; it lasts 30 minutes to a few hours after alcohol use stops. Alcohol and alcohol-containing products should be avoided (e.g., mouthwash, cold medications) while taking and up to two weeks after stopping disulfiram. Patients should be thoroughly educated and carry a medical alert card. Dosage is 250 mg Tablet once/day; patient must be abstinent at least 12 hours from alcohol and alcohol-containing products to begin medication. Side effects are usually minor and transient, but may include drowsiness, fatigue, metallic or garlic aftertaste, skin rash or acne, headaches, and impotence. Very rarely can cause serious liver injury; liver function should be tested prior to and regularly during treatment. A good candidate might be a highly motivated alcoholic with poor impulse control who uses despite multiple treatment episodes.

Acamprosate (Campral®)

Campral® is effective in post withdrawal maintenance of alcohol abstinence. Campral® acts on the GABA and glutamate neurotransmitter systems and is believed to work by reducing symptoms of post acute (protracted) withdrawal, such as insomnia, anxiety, and restlessness. Campral® is an oral medication with a recommended daily dose of two (2) 333mg tablets three times a day. Patients must be abstinent from alcohol before beginning treatment. It is well tolerated and common side effects are diarrhea and abdominal discomfort. Campral® does not stop patients from consuming alcohol, nor does it precipitate any physical symptoms when alcohol is consumed.

Topiramate (Topamax®), ondansetron (Zofran®) and baclofen are other medications that have been found to be effective in alcohol dependence in clinical research.

Abrupt cessation of alcohol after chronic regular heavy drinking leads to alcohol withdrawal syndrome. The severity of withdrawal syndrome depends upon several risk factors that need to be assessed. Severe alcohol withdrawal is a medical emergency because of risk of seizures, and delirium tremens (DT) and requires hospitalization for effective management. Mild to moderate withdrawal symptoms can be managed in an outpatient setting. Once comorbid illnesses have been excluded or adequately treated, the management of alcohol withdrawal is directed at alleviating symptoms and identifying and correcting metabolic derangements. Benzodiazepines are used to control psychomotor agitation and prevent progression to more severe withdrawal. Supportive care, including hydration, nutritional supplementation, and frequent clinical reassessment including vital signs, is important.

For alcohol-dependent individuals who can be safely detoxified in an ambulatory setting, Avance Psychiatry offer medically supervised outpatient detoxification using tapering doses of benzodiazepines along with adjuvant medications. We favor a symptom-triggered approach to the treatment of alcohol withdrawal that involves providing medication only when a patient has symptoms. To use this approach, a regular systematic assessment is made of the patient’s status using a validated instrument, such as the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar), a measure of withdrawal severity and using additional benzodiazepines when the scores are elevated.

There are no FDA approved medications to treat cocaine, methamphetamine, or prescription stimulant (Adderall®, Ritalin®) addiction and the primary modality of treatment is behavioral therapy. However, there is scientific evidence that some of the existing medications may be beneficial. As with most types of addiction, the first phase of treatment is detoxification. In this phase, abusers will decrease and discontinue use of the substance, under the supervision of a medical professional to help reduce the severity of potential withdrawal symptoms. Stimulants do not produce significant physical dependence and withdrawal symptoms are primarily psychological and behavioral. Symptoms include low mood, anxiety, irritability, fatigue, and cravings.

Medications are often used during the treatment process for symptom relief and include available medications such as antidepressants, anti-anxiety medications, anticonvulsants, and disulfiram. The cornerstone of treatment is primarily behavioral therapy. Most patients benefit from frequent structured group and individual behavioral therapy sessions. Our clinicians provide adjuvant medications that are marketed for other diseases (e.g., modafinil, tiagabine, disulfiram, and topiramate) and have shown promise to reduce stimulant use in research trials. Our counselors are skilled in behavioral therapies to assist in recovery from stimulant addiction.

Benzodiazepines (Xanax®, Valium®, Klonopin®, Librium®, Restoril®) are commonly used for the treatment of insomnia, anxiety, seizures, muscle spasms, alcohol withdrawal, and a number of other conditions. When used appropriately over a short period of time, they can be very effective; however, when misused they can cause physical dependence and addiction. Other sedative hypnotic medications such as Ambien®, and Lunesta® if misused, also produce physical dependence and addiction. Benzodiazepine addiction can involve both physical and a psychological dependence on the drugs, resulting in withdrawal when doses are stopped or reduced. Withdrawal symptoms include anxiety, mood swings, insomnia, fatigue, poor concentration, and depersonalization. Some of these symptoms continue after the acute withdrawal is over and is termed post-acute withdrawal syndrome. Abrupt cessation of benzodiazepines can lead to seizures and psychosis and is not recommended in a dependent individual.

Treatments for benzodiazepine addiction generally begin with a slow medically supervised detoxification process, eventually weaning a person away from the effects of the drugs while attempting to decrease the severity of the symptoms of withdrawal. Doctors will use a long acting slowly metabolized benzodiazepine like Valium® for outpatient detoxification. The dose reduction is 5-10% per week initially and can be slower as the dose is lowered. The process is slow and can take several weeks.  It can be accomplished in an outpatient setting in motivated individuals with good support and no complicated medical disorders. High dose benzodiazepine addiction often needs inpatient detoxification followed by outpatient continuing care. At Avance Psychiatry, clinicians follow established guidelines for benzodiazepine detoxification and use adjuvant medications and behavioral therapy to address comorbid psychiatric conditions.

Individuals with alcohol and other substance use disorders have a high rate of tobacco use. Often patient continue or even increase their tobacco use after they have quit alcohol and illicit drugs. At Avance Psychiatry, we believe in educating patients about the benefits of smoking cessation and the cessation process. We discuss and offer approved medications to help in smoking cessation. These include nicotine replacement therapies (NRT) such as nicotine transdermal patch, gum, lozenge, inhaler and spray, medications such as bupropion (Zyban®) and varenicline (Chantix®). Our counselors are trained in cognitive behavioral therapy (CBT) and other counseling approaches that have been shown to be effective in smoking cessation.

The term “co-occurring disorders” typically refers to an individual having co-existing mental health and substance use disorders. There is a high rate of psychiatric disorders such as depressive disorders, anxiety disorders, post-traumatic stress disorders (PTSD), attention-deficit hyperactivity disorders (ADHD), bipolar disorders, impulse control disorders (e.g., pathological gambling) and eating disorders in individuals with alcohol and other substance addiction.

There is a bi-directional relationship with psychiatric disorders contributing to alcohol and drug use and substance use worsening psychiatric disorders. Undiagnosed and untreated co-occurring psychiatric disorders are likely to hinder recovery from alcohol and drug addiction. At Avance Psychiatry, we systematically evaluate for the presence of psychiatric disorders. Diagnosis of co-occurring disorders often require a period of abstinence from alcohol and drugs and good collateral information. FDA approved medications are usually effective to treat co-occurring disorders after detoxification from alcohol and other drugs. Behavioral treatments are important components of overall management. At Avance Psychiatry, we follow an integrated approach to treat psychiatric and addictive disorders at the same time with appropriate medications and behavioral therapies to enhance recovery.