The Science of Recovery: Applying Neuroscience to CLINICAL Practice STIMULANT

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The Science of RecoveryApplying Neuroscience to
CLINICAL PracticeSTIMULANT OPIOID ADDICTION

• Cardwell C. Nuckols MA, PhD
• cnuckols_at_elitecorp.org
• [phone]

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SUGAR OR COCAINE

• RATS CHOOSE HIGHLY SWEETENED SUGAR WATER OVER IV
  COCAINE
• RATS WHO WERE ALREADY COCAINE USERS (I.E.
  SELF-ADMINISTERED) STILL CHOOSE VERY SWEET WATER
• RATS ON HIGH SUGAR DIET EXHIBIT AAS WHEN
  WITHDRAWN
• Scientific American Mind Apr/May 2008, pg. 16

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Overview

• Dopamine and the Seeking System
• Recovery Tools
• Wellness
• Education
• Craving and Craving Mnageent
• Stimulants
• Opioids

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SEEKING SYSTEM

• IN 1954 JAMES OLDS AND PETER MILNER OF MCGILL
  UNIVERSITY DISCOVERED WHAT THEY REFERRED TO AS
  THE REWARD, PLEASURE OR REINFORCEMENT SYSTEM
• WHAT THEY ACTUALLY DISCOVERED WAS A SYSTEM THAT
  IS INTEGRATED THROUGHOUT THE BRAIN AND MIGHT BE
  BEST DESCRIBED AS THE SEEKING SYSTEM

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SEEKING SYSTEM

• THESE CIRCUITS APPEAR TO BE MAJOR CONTRIBUTORS
  TO OUR FEELINGS OF ENGAGEMENT AND EXCITEMENT AS
  WE SEEK THE MATERIAL RESOURCES NEEDED FOR BODILY
  SURVIVAL, AND ALSO WHEN WE PURSUE THE COGNITIVE
  INTERESTS THAT BRING POSITIVE EXISTENTIAL MEANING
  INTO OUR LIVES.

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SEEKING SYSTEM

• HIGHER AREAS OF THE MOTOR CORTEX ARE ALSO
  ENERGIZED INTO ACTION BY THE PRESENCE OF DA.
  WITHOUT THE SYNAPTIC ENERGY OF DA, THESE
  POTENTIALS REMAIN DORMANT AND STILL. WITHOUT DA,
  HUMAN ASPIRATIONS REMAIN FROZEN, AS IT WERE, IN
  AN ENDLESS WINTER OF DISCONTENT.
• PANKSEEP, J. AFFECTIVE NEUROSCIENCE. OXFORD
  UNIVERSITY PRESS. NEW YORK, 1998, PG 144.

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SEEKING SYSTEM

• WITHOUT DA ONLY THE STRONGEST EMOTIONAL MESSAGES
  INSTIGATE BEHAVIOR
• WHEN DA SYNAPSES ARE ACTIVE IN ABUNDANCE PERSON
  FEELS LIKE THEY CAN DO ANYTHING
• IT IS NO MYSTERY WHY COCAINE, METHAMPHETAMINE AND
  OTHER DRUGS ARE SO REINFORCEING

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SEEKING SYSTEM

• DA EXCESS
• MAY SEEK SPIRITUAL HEIGHTS
• APPEAR MANIC ( IN EARLIER TIMES MAY BE
  REPRESENTED BY SEERERS, SOOTHSAYERS, SHAMAN)
• OUR IMAGINATION OUTSTRIPS THE CONSTRAINTS OF
  REALITY
• BEGIN TO SEE CAUSALITY WHERE THERE IS ONLY
  CORRELATION

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SEEKING SYSTEM

• DA EXCESS (CONTINUED)
• HIGH ANTICIPATION, INTENSE INTEREST AND
  INSATIABLE CURIOUSITY
• MOST ARRESTING PART IS THE HUNT, NOT THE CAPTURE
• DA IS RELEASED FROM THE VENTRAL STRIATUM (NUCLEUS
  ACCUMBENS) OF RATS QUITE VIGOROUSLY DURING THE
  ANTICIPATION PHASE BUT NOT DURING THE CONSUMATORY
  PHASE

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SEEKING SYSTEM

• CRITICAL CIRCUITS
• MEDIAL FOREBRAIN BUNDLE OF THE LATERAL
  HYPOTHALAMUS (LH)
• EXTENDED LATERAL HYPOTHALAMIC CORRIDOR (LH)
• RESPONDS TO HOMEOSTATIC IMBALANCES (BODY NEED
  STATES)
• ENVIRONMENTAL INCENTIVES
• LH CONTINUUM RUNNING FROM VTA TO NAc
• WHEN EVOKED GET STRONGEST AND MOST ENERGIZED
  EXPLORATION AND SEARCH BEHAVIORS

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SEEKING SYSTEM

• CRITICAL CIRCUITS (CONTINUED)
• BASIC IMPULSE TO SEARCH, INVESTIGATE AND MAKE
  SENSE OF ENVIRONMENT EMERGES FROM THE CIRCUITS
  THAT COURSE THRU THE LH
• NEUROEMOTIONAL SYSTEM THAT DRIVES AND ENERGIZES
  MANY MENTAL COMPLEXITIES THAT HUMANS EXPERIENCE
  SUCH AS PERSISTENT FEELINGS OF INTEREST,
  CURIOUSITY, SENSATION SEEKING AND IN THE PRESENCE
  OF A SUFFICIENTLY COMPLEX CORTEX-THE SEARCH FOR
  HIGHER MEANING

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SEEKING SYSTEM

• SENSITIZED BY
• EXTERNAL STIMULI THAT CAN HAVE EITHER STRONG OR
  WEAK INTERACTIONS WITH THIS EMOTIONAL SYSTEM
• HELPS MEDIATE APPETITIVE LEARNING SO THAT ANIMALS
  WILL BECOME EAGER AND EXHIBIT EXPECTANCIES IN
  RESPONSE TO PREVIOUSLY AROUSING CUES
  (REINFORCEMENT)

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Dopamine D2 Receptors

• Association between DA D2 receptor numbers and
  drug self-administration
• Increased D2 receptors reduced alcohol
  consumption
• Decreased D2 receptors higher risk
• DA D2 receptor levels influenced by stress and
  social hierarchy
• Helps explain influence of environment and genes

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Environment And Social Status

• Subordinate animals more likely to
  self-administer cocaine
• Dominant animals no more likely to
  self-administer cocaine than placebo
• Social interventions can change neurobiology
• Increased DA D2 receptors
• Reduced self-administration
• Behavioral interventions could counteract the
  aversive effects of drug abuse and reinforce the
  power of group approaches

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Group Behavioral Interventions

• Group Therapy
• Active participation
• Successful completion of assignments
• Milieu
• Leadership
• Modeling
• Self help
• Coffee and chairs
• Telling story

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Recovery Epigenesis

• Facilitated by
• NOVELTY
• ENVIRONMENTAL ENRICHMENT
• PHYSICAL EXERCISE
• NUTRITION
• PLAY
• BDNF

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Novelty-Examples

• Group Therapy
• Individual Counseling
• Sober Living
• Higher Power
• Assessment
• Alcohol/Drug
• Psychosocial

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Environmental Enrichment-Examples

• Recovery housing
• Healthy milieu
• Self help meetings
• Church
• From isolation to living one day at a time in
  the presence of others striving for a more
  fulfilling life

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Physical Exercise

• Stimulates production of brain-derived
  neurotrophic factor (BDNF)
• Neurotrophin that governs maturation and
  development of neural systems
• Enhances executive functioning
• Obey social rules
• Adapt to changing unpredictable environment
• Short term working memory
• Multi-tasking
• Self-directedness

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Physical Exercise

• Self-directedness
• Responsible
• Purposeful
• Resourceful
• Increases neurotransmitters
• Monoamines
• Serotonin
• Dopamine
• Norepinephrine

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Education

• Why give an alcoholic or addict a 60 minute
  didactic or video?
• A new format
• 15-20 minute simple didactic
• How to participate in treatment
• 10 minute questionnaire
• 30 minute discussion group

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10 Minute Questionnaire
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CRAVING

• CLASSIFIACTION OF CRAVING
• Situational triggers
• Environment (People, Places And Things)
• Emotional triggers
• Internal (Hungry, Angry, Lonely, Tired, Reward
  and Bored)
• Acute Abstinence Syndrome
• Stress

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CRAVINGMOST COMMON CRAVING TRIGGERS

• In presence of
• Alcohol and drugs
• Alcohol and drug users
• Places where used to use or purchase
• Negative feeling states particularly anger but
  also
• Boredom
• Loneliness
• Fear
• Anxiety

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MOST COMMON CRAVING TRIGGERS

• Positive feeling states
• Physical pain
• Use of mood-altering prescription drugs
• Suddenly having a lot of cash
• Complacency
• Insomnia
• Sexual functioning

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STIMULANT ADDICTIONChildhood Trauma History and
Methamphetamine Addiction

• 44 of women and 24 of men entering treatment
  for methamphetamine addiction report childhood
  sexual abuse
• 32 of women and 34 of men report childhood
  physical abuse
• 56 reported parental alcohol and/or drug
  problems
• Multigenerational
• Brown University Digest of Addiction Theory and
  Application. May 2004

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STIMULANT ADDICTION Meth's Long Lasting
EffectsNeuron (April 10, 2008) Bamford, Nigel

• Novelty causes increased DA
• Increased DA causes reduced Glutamate
• Causes filtering of irrelevant information and
  strong focus on a single object or event
• After novelty disappears DA is reduced and
  Glutamate returns to normal

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STIMULANT ADDICTION Meth's Long Lasting
EffectsNeuron (April 10, 2008) Bamford, Nigel

• In chronic meth use
• Meth causes increased DA and reduced Glutamate
• After drug is gone glutamate stays low in spite
  of reduced DA
• Source of continuing low Glutamate is
  Acetylcholine
• After prolonged meth use Acetylcholine stays low
  effectively blocking Glutamate release.

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STIMULANT ADDICTION Meth's Long Lasting Effects

• Paranoid psychosis
• Homicidal and suicidal thought, rage, violence
  and hallucinations
• Generally angry toward people they know and
  paranoid toward strangers or strange situations
• Damage to dopamine-producing neurons
• Damage to serotonin-producing neurons
• Effects on cognition and affect (depression)
• Damage to heart and blood vessels
• Skin abscesses and skin infections
• Increased risk of Hepatitis B and C, HIV

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CRAVING MANAGEMENT

• Psychotherapy
• Group Approaches
• Behavior Therapy
• Structure
• Recovery Foundation Program
• Changing patterns
• Safety Plan
• Pharmacotherapy

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Stimulant Treatment

• Cognitive-Behavioral strategies to promote
  abstinence and prevent relapse
• Avoidance of high risk situations
• Educating about triggers and craving
• Training in thought stopping
• Reinforcing principles of verbal praise by
  therapist and peers

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Stimulant Treatment

• Relapse
• Reframe event, not a failure
• May need to go back to Early Recovery Sessions
• Repeated as indicator of need for more
  restrictive level of care
• Urinalysis
• Reevaluate the period surrounding the test
• Give patient opportunity to explain
• Dont get into validity of test argument
• May need to increase number of tests
• Consider LOC

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STAGES OF RECOVERY
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Roadmap for RecoveryEarly Abstinence Features
(Honeymoon)
Overconfidence Difficulty Concentrating Continued
Memory Problems
HONEYMOON
Intense Feelings Mood Swings Other Substance
Abuse Inability to Prioritize
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Roadmap for RecoveryTechniques for Thought
Stopping

• Learn to recognize using thoughts
• Use visual imagery
• Relaxation
• Prayer
• Call someone

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Thought Stopping

• First one must become aware of their automatic
  thoughts-need some form of self-monitoring
• Second one must have an alternative positive
  thought or behavior to put in its place
• Some people get rebound effect

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Thought Stopping

• Thought Replacement
• Yelling stop
• Replacement visual image
• Aversive replacements
• Using rubber bands

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Roadmap for Recovery
PROTRACTED ABSTINENCE
Emotional Swings Unclear Thinking Isolation Family
Problems
Return to Old Behaviors Anhedonia Anger Depression
Cravings Return Irritability Abstinence Violation
THE WALL
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What Is Protracted Abstinence Syndrome (PAW)

• STRESS SENSITIVE
• NEUROLOGICAL SYNDROME
• STARTS AFTER THE ACUTE ABSTINENCE SYNDROME
• LASTS FOR MONTHS (SOMETIMES MORE) INTO RECOVERY
• FOR METH 6-20 WEEKS

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CORE SYMPTOMS

• SYMPTOM SEVERITY BASED ON LEVEL OF NEUROLOGICAL
  DYSFUNCTION AND DEGREE OF PSYCHOSOCIAL STRESS
• Restlessness and Irritability
• Euphoric Content Dreams
• Anxiety
• Distractibility
• Intense Craving
• Executive Functioning
• Visual-spatial

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MANAGEMENT OF PAW(NEUROPSYCHOLOGICAL
REHABILITATION)

• RELATIONAL AND SPIRITUAL
• EDUCATION
• MANAGEMENT OF CRAVING AND PAW
• LIFESTYLE ASSESSMENT
• NUTRITIONAL
• SLEEP/WAKE
• BEHAVIORAL MANAGEMENT
• FOUNDATION PROGRAM
• SAFETY PLAN
• PHARMACOLOGICAL

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Pharmacological Management-Reducing Relapse

• Stimulant drugs-Cocaine and Methamphetamine
• Gamma-vinyl GABA (Vigabatrin)
• Attenuates or blocks reward seeking behaviors
• Modafinil (Provigil)
• Treatment for Narcolepsy
• Increases mood, energy, and sense of well-being
• Reduces daytime sleepiness
• Selegiline (Carbex, Atapryl)
• MAOI
• Believed to restore depleted dopamine

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Changing Patterns

• 31 yo Nicki-a recovering methamphetamine addict-
  just got her first paycheck. She cashed her check
  and cruised thru the neighborhood where she used
  to score dope. Rock music blared from her
  speakers. Soon she was thinking, "I worked hard
  all week. I deserve a little fun.

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Behavioral Foundation Program

• In an inpatient setting the patient schedule
  serves this purpose
• On an outpatient basis or upon discharge from
  inpatient a recovery plan or contract is
  appropriate
• Remember that most addicts have little or no
  recent experience living a drug free lifestyle

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Behavioral Foundation Program
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Behavioral Foundation Program

• Carter is 24 yo and just getting out of treatment
  for alcohol and drug addiction
• His early A/D history included.
• Started drinking on Friday nights with friends in
  high school
• Turned-on to methamphetamine and marijuana by
  friends on weekends
• Started to buy drugs to sell from a distributor
  on Wed nights

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Using Early Drug History
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Behavioral Safety Plan

• CT Last night I had a dream that I was getting
  ready to shoot dope-it was all on the table in
  front of me. It was like five minutes before I
  knew it was a dream.
• TH Congratulations on not using, tell the group
  what you did to deal with the craving.
• CT I went into the kitchen and wrote in my
  journal everything that happened. Then I said a
  prayer.

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Behavioral Safety Plan

• TH What else could you have done?
• CT I know that I can always call my sponsor or
  my lover. I can also read from a book that I have
  on recovery or a book of affirmations that I
  like.
• TH Thats great. Now lets make a safety plan
  from what you have discovered.

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Behavioral Safety Plan On 3x5 Index Card
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Behavioral Safety Plan On 3x5 Index Card

• TH On the back of the index card, come up with
  a saying or a prayer that gives you comfort and
  strength.
• CT I have always liked Lord help me to be
  the best possible person I can be today.

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Stimulant AddictionMedical Management

• Modafinil
• Agents that increase GABA
• Topiramate
• Vigabatrin (gamma-vinyl-GABA)

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OPIOIDS

• Natural
• Morphine
• Codeine
• Semi-synthetic
• Heroin
• Oxycodone
• Tylox
• Percodan
• OxyContin

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OPIOIDS

• Semi-synthetic
• Oxymorphone
• Dilaudid
• Numorphan
• Hydrocodone
• Lortab
• Vicodin
• Synthetics
• Methadone
• Propoxyphene
• Lomotil

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Heroin Abstinence Syndrome

• Increased Noradrenergic activity
• Begins 10-12 hours after last dose
• Peaks at 2-3 days
• Lasts 7-10 days

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Symptoms of the Abstinence Syndrome

• Addicts Experience
• A hyper-aroused state(fight or flight)
• Increased
• Heart rate
• Blood pressure
• Restlessness
• Tremors
• Hypervigilence
• Dilated pupils

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Symptoms of the Abstinence Syndrome

• Addicts experience
• Worst case of flu imaginable
• Nausea and vomiting
• Runny nose
• Cold, shivering
• Cramping
• Tearing
• Diarrhea

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Subjective Experience

• 4 levels of experience
• High
• Abnormally normal
• Subjective withdrawal
• Physical withdrawal
• Routes of administration
• IV
• Oral
• Pulmonary

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Pharmacological Treatment Acute

• Methadone.
• Inpatient.
• 40 mg. In 4x10mg doses.
• Observe every 2 hours.
• If sleepy reduce next dose by 5mg.
• In withdrawal add 5mg.
• After 24 hours withdraw at a 5mg. per day rate.

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Pharmacological Treatment Acute

• Methadone
• Outpatient
• 40- 60mg. Divided into 2 doses
• After 2nd day withdraw at 2.5mg. per day
• Clonidine(Catapress TTS)
• 1.2mg. Per day in 3 divided doses
• 2 or 3 2 patches
• May mask sedative/hypnotic withdrawal
• Can combine with Phenobarbital
• Lofexidine

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Rapid Detoxification

• Procedure administered in ICU
• Use of anesthesia
• Opiate receptor blocker(Naltrexone)
• Physical reaction closely monitored
• Process complete in 4-6 hours

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Symptomatic Treatment

• PRN meds for the first days.
• Bentyl 10mgs. for abdominal cramps.
• 30mgs. po q 4-6hours.
• Imodium 2mgs. for diarrhea.
• 1-2 caps after 1st observed stool.
• Not to exceed 60 mgs. Per day.
• Robaxin 750mgs. for muscle spasm or pain.
• 1-2 q 6-8 hours.

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Pharmacological Maintenance

• Opioid Maintenance Medications
• Methadone
• LAAM
• Buprenorphine
• Naltrexone

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Pharmacological

• Naltrexone (Revia, Vivitrol)
• Pure antagonist
• Poor compliance
• Less than 10 for street addicts
• Better compliance
• Healthcare professionals
• Parole/Probation
• New suspension with q30d administration should
  dramatically increase compliance and reliability
  of drug

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Approved Buprenorphine Products

• Subutex-Buprenorphine. sublingual (SL)
• 2mg and 8mg tablets
• Suboxone-Buprenorphine/Naloxone SL tablets
• Buprenorphine 25-50 xs more potent than morphine
• Partial agonist
• Increasing dose does not increase effect like a
  full agonist

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Buprenorphine-Affinity and Dissociation

• Very high affinity for mu opioid receptor
• Mu receptor will choose buprenorphine over other
  opioids
• Buprenorphine will displace other opioids
• Slow dissolution from mu receptor
• Half-life on receptor is 34-36 hrs
• Heroin on and off receptor in millisecond
• At Buprenorphine dose of 16mg almost no binding
  to other opioids

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Combination of Buprenorphine and Naloxone

• If taken under the tongue you get predominant
  buprenorphine effect
• If dissolved and injected get predominant
  naloxone effect (precipitates withdrawal)

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Buprenorphine Induction

• Buprenorphine equally effective as 60 mg of
  Methadone per day
• If patient needs 80-100 or more mgs of Methadone
  to be comfortable, Buprenorphine probably will
  not work
• With client dependent on short-acting opioids
• Instruct client to abstain for 12-24 hours
• Need to be in mild withdrawal before first dose

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DOPAMINE (DA) TONE

• TWO TYPES OF LOW DA TONE
• DA RECEPTOR SIGNAL AT NUCLEUS ACCUMBENS (NAc)
• OPIOID RECEPTOR SIGNAL AT VENTRAL TEGMENTAL AREA
  (VTA)
• CAN INVOLVE ANY PART OF MECHANISM FOR SIGNAL
  CONDUCTION
• TWO NEUROTRANSMITTER SYSTEMS FORM A POSITIVE
  FEEDBACK LOOP, EACH CAUSES AN INCREASE IN THE
  OTHER
• WHEN NOT FUNCTIONING PROPERLY GET LESS THAN
  NORMAL HEDONIC RESPONSE TO STIMULI

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Reward Pathways
Ventral Tegmental Area
Nucleus Accumbens
Dopamine
ArcuateNucleus
Opioid Peptides
Naltrexone
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DOPAMINE (DA) TONE

• TWO TYPES OF LOW DA TONE (CONTINUED)
• SYMPTOMS WILL BE THOSE OF REDUCED DA TONE AT NAc
  REGARDLESS OF THE LOCATION OF FEEDBACK PROBLEM
• FROM TREATMENT PERSPECTIVE WHAT DIFFERENTIATES
  WHETHER DA OR OPIOID CAUSATION OF LOW DA TONE
  IS.
• HISTORY OF DRUG USAGE AND EFFECTS THAT USER
  EXPERIENCES

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DOPAMINE (DA) TONE

• DA RECEPTOR SIGNAL AT NAc
• COULD HAVE NORMAL FUNCTIONING VTA AND NORMAL
  FUNCTIONING OPIOID RECEPTOR ON VTA
• LIKE DRUGS THAT CAUSE DIRECT INCREASE IN DA AT
  THE NAc OR DIRECTLY STIMULATE THE NAc
• DRUGS ACTING ON OPIOID RECEPTOR WILL NOT PROVIDE
  MUCH OF A REWARD BECAUSE SYSTEM IS FUNCTINING
  NORMALLY
• MAY USE OPIOIDS BUT AT BEST WILL BE A SECOND
  CHOICE
• DOC WILL BE STIMULANTS OF ALL TYPES INCLUDING
  NICOTINE

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DOPAMINE (DA) TONE

• OPIOID RECEPTOR SIGNAL AT VTA
• DRUGS THAT INCREASE DA NOT AS EFFECTIVE
• DOC ARE OPIOID AGONISTS
• COCAINE DOESNT WORK VERY WELL UNLESS COMBINED
  WITH OPIOID
• METHAMPHETAMINE CAUSES ADDITIONAL RELEASE OF DA
  AT NAc RATHER THAN JUST REUPTAKE INHIBITION
  (MIMICS THE EFFECT OF OPIOID), NICOTINE
  STIMULATES DA RELEASE
• PT. MAY STATE THAT LIKES METH AND COKE DOESNT
  WORK VERY WELL

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DOPAMINE (DA) TONE

• COULD HAVE BOTH TYPES OF REDUCED DA TONE (DA AND
  OPIOID)
• OCCURS IN APPROXIMATELY ONE-HALF OF OPIOID
  DEPENDENT PTS
• IF GIVE THEM BUPRENORPHINE MAY CONTINUE TO SMOKE
  OR SMOKE MORE
• VTA MAKES MORE DA SO SMOKING IS MORE REWARDING
• EVIDENCE OF LOW DA TONE

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DOPAMINE (DA) TONE

• BUPRENORPHINE
• PARTIAL MU AGONIST
• KAPPA OPIOID ANTAGONIST
• ANECDOTAL PERSPECTIVES BUPRENORPHINE/NALOXONE
  (SUBOXONE)
• TITRATION WORKS BEST WHEN PERFORMED QUICKLY
• KEEPS PTS FROM LEAVING TREATMENT DUE TO UNDER
  DOSING
• USING 10 POINT SCALE (1 IS FEELING COMPLETELY OK
  AND 10 IS WORST IVE FELT OFF OF OPIOIDS)

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DOPAMINE (DA) TONE

• TITRATION WORKS BEST WHEN PERFORMED QUICKLY
  (CONTINUED)
• TAKE 4 MG AND CALL IN 2 HOURS
• IF NOT AT 1 TAKE 4 MG AND CALL IN 2 HOURS
• CONTINUE UNTIL PT IS COMFORTABLE
• MAY GET HIGHER INTIAL DOSE THIS WAY BUT CAN
  REDUCE AFTER 1 WEEK
• SWALLOWING BUPRENORPINE MAY CREATE ADVERSE
  SYMPTOMS OF HEADACHE OR NAUSEA
• MAY BE RELATED TO SWALLOWING THE
  BURPENORPINE/NALOXE/SALIVA MIXTURE
• SWALLOWING MAY CAUSE INCREASE IN NALOXONE
  ACTIVITY

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DOPAMINE (DA) TONE

• SWALLOWING BUPRENORPINE MAY CREATE ADVERSE
  SYMPTOMS OF HEADACHE OR NAUSEA (CONTINUED)
• HAVE PT LEAN FORWARD IN CHAIR AND READ FOR 10
  MINUTES
• SPIT OUT SALIVA
• IF PT SAYS THAT SUBOXONE MAKES THEM NOD OUT
• HIGHLY UNLIKELY THAT SUBOXONE WILL CAUSE THIS
• CHECK TO SEE IF THEY HAVE EATEN A HEAVY MEAL
  PRIOR TO TAKING MED OR IF THERE IS A SLEEP
  PROBLEM
• IN ADDICTION MEDICINE THE ONLY TIME THAT SUBUTEX
  SHOULD BE USED IS WITH PREGNANT FEMALE
• CONCERN AT HIGH DOSES (EXAMPLE 32 MG) MAY ABSORB
  ENOUGH NALOXONE TO CAUSE PROBLEMS-THIS IS
  EXTREMELY RARELY THE CASE

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DOPAMINE (DA) TONE

• WHEN USING SUBOXONE FOR PAIN
• BURENORPHINE IS A VERY POTENT PAIN RELIEVER
• ADDICTION STABILIZATION EFFECT IS LONG LASTING
• HOWEVER, PAIN RELIEF EFFECT IS SHORT ACTING
• THEREFORE DIVIDE THE DOSE INTO SMALLER PORTIONS
  AND GIVE MORE FREQUENTLY
• FOR EXAMPLE, IF ON 16 MG QD, GIVE 4MG QID