I’m Dr. Brian Clear, Medical Director at Bicycle Health, the leading provider of virtual opioid addiction treatment. Today, I’ll be joined by Bicycle Health’s CEO + Founder, Ankit Gupta, to discuss opioid use disorder recovery and treatment in hon...

What's virtual opioid addiction? Like counselling online? How to you prescribe substitutes then? I'm in the uk and have to have face to face meetings with my key worker every three months or they'll stop my prescription.

It generally includes counseling online, either group-based or individual. It also includes online visits with a doctor, PA, or NP, who specializes in addiction medicine and can provide medical treatment with buprenorphine (Suboxone). Of the 3 effective medical treatments for OUD, buprenorphine is the one that can be accessed and provided safely online.

buprenorphine is the one that can be accessed and provided safely online

Could you elaborate on this please? In my experience, I've seen suboxone abused more than methadone (I don't know what the 3rd MAT is). I've rarely seen methadone used for anything but relief of withdrawal symptoms but many people who used IV opiates will wind up using suboxone intravenously and recreationally. I don't understand why the 2 medications are treated so differently.

Thank you!

I’m biased as I’m a big advocate of MAT and suboxone in particular but there are some key qualities of suboxone (and buprenorphine generally) that make it advantageous. For one, yes we can acknowledge that it is possible to abuse, misuse, or divert suboxone. However, in the context of a harm reduction model I think this is a risk that we can all accept. Bupe is a partial opioid against so it has a ceiling effect for both pleasurable/euphoric effects as well as respiratory depression whereas full agonists (methadone, heroin, fentanyl, etc) have no such ceiling effect. So bupe is much much safer (lower overdose risk) and much less likely to be abused than the full agonists. In my clinical experience most people who do “abuse” bupe or use it illicitly don’t do so to get high but merely to avoid withdrawal. If the goal is to get high then there are many other opioids that are far superior than bupe to achieve this goal. And if someone is going to abuse drugs, by administering them IV as you note, personally I’d prefer them to abuse bupe than almost any other opioid because they have a much lower risk of dying by overdose if they do so. Now, this is obviously not the goal of MAT but just my two cents.

These properties are why suboxone has generally fewer restrictions than methadone and why it can be prescribed virtually (though my guess is that this last point is subject to different state laws).

What can be done to help someone who is already addicted to recreational subs then? They wouldn't be able to go get a prescription and wean down like legit-style would they?

A medical provider can prescribe buprenorphine (Suboxone) for Opioid Use Disorder, which has 2 parts: addiction + dependence. Dependence is the same as having tolerance to an opioid, meaning your body is adapted to taking the opioid regularly, and you experience withdrawal when you stop it. You can have dependence without addiction if you take a medication like an opioid regularly but experience no psychological or social problems as a result of that drug. When psychological or social problems develop, i.e. you're distressed about not being able to find the drug, continuing to use the drug despite a desire to stop, repeated difficulty stopping despite trying, job loss, relationship loss, giving up hobbies and things you enjoy in order to obtain the drug: that's addiction. You can develop opioid use disorder (addiction + dependence) from recreational Suboxone like you can from other opioid use if obtaining the drug illicitly is causing the psychosocial problems of addiction. In that case, yes, it's legal and also the right medical decision for a provider to offer prescribed buprenorphine (Suboxone) treatment.

I love this article that gives a thorough review of the risk of diversion or misuse of treatment for opioid use disorder and puts it in perspective.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800751/

Also beautifully well-stated by korndog42.

Methadone is extremely tightly regulated (when used for addiction treatment) so it's less commonly diverted or misused because it's less available. Buprenorphine (Suboxone) is more widely available so will be found more commonly on the street, but it also has much lower harm potential than methadone when used recreationally or as self-directed treatment. There will be more stories of misusing buprenorphine from the street and having a bad experience, but you'll hear the stories because the experience is survived. You won't hear many stories of mixing street methadone with fentanyl because it's extremely lethal.

Suboxone is most definitely abused more than methadone according to the SA patients my wife treats regularly. I don't know how they came to the conclusion that it can be provided safely online.

as it puts opiate addicts into precipitated withdrawal without a taper, I highly doubt its more abused than methadonw. Usually a patient goes from active addiction > methadone > suboxone for this reason. Also suboxone is a partial antagonist so the high isn't nearly as good.

That's only true sometimes. I take both oxycodone and buprenorphine, and I had zero problems when the buprenorphine was started, because I titrated up the dose, rather than starting at a high dose of buprenorphine.

yup, a micro-dosing start! The precipitated withdrawal reaction happens because of a very sudden shift from full opioid-receptor activation to the partial-activation state that buprenorphine provides. When the shift is abrupt, it's awful. The classic way to avoid this is to allow withdrawal to develop over anywhere from 6 to 72 hours, depending on the person and the opioid used, then start buprenorphine to quickly relieve the withdrawal state.

A micro-start instead very slowly starts buprenorphine which can be done while a person is still using other opioids, and it works well. The trick with a micro-start is that it involves complex directions that go on for a week or more before a stable dose is achieved. It can be a lot for some to manage, it takes longer than a classic start, and many prefer to stop illicit opioids immediately when they start treatment rather than potentially continuing to take them for a week while working up to an effective Suboxone dose.

It's not the buprenorphine that causes the withdrawals, it's the naloxone in it. Afaik there is subutex and suboxone, but subutex doesn't have the naloxone in it.

No it is the buprenorphine that causes precipitated withdrawals because it has stronger binding affinity then other opioits/opioids. Meaning buprenorphine knocks other opioits off the receptors causing the person to go into what is know as precipitated withdrawals which is hellish. The naloxone in Suboxone does almost nothing, if anything it was used as a marketing gimmick and saying it couldn't be injected/snorted because of it.

yes. the naloxone is inactivated extremely quickly when absorbed through the mouth, stomach, or intestines, and does nothing. It would only be active if injected or, less so, snorted. that's why to effectively "Narcan" somebody it must be administered by injection or a nasal spray; it would be ineffective if squirted into someone's mouth or swallowed.

FL private residential SA experience, active addiction > suboxone+therapy > discharge w/ suboxone script > OD >death/readmission. Very common trend down here.

right. its not uncommon for opiate addicts to use while on suboxone. unfortunately, when this happens the person increases the dose of illicit substance, and especially with synthetics like fentanyl, they are not able to judge tolerance level correctly, so they OD.

the initial statement is sort of correct. The follow-up assumption is not. Return to illicit use is very common in OUD treatment, usually following discontinuation of treatment but sometimes during treatment. When a return to illicit use, 'relapse,' happens during treatment, rates of overdose are extremely low as long as an effective dose of buprenorphine is being used.

buprenorphine has been used effectively in emergencies to reverse an overdose when Narcan is not available. It is such a potent blocker of the effects of other opioids, it reduces overdose risk when combined with other opioids rather than increasing it (like any other opioid would do). That's not to say it's preferred; Narcan works MUCH better, but I think it's telling to know that its overdose-prevention effect is so potent it can even help in this situation when nothing else is available.

Yes, it is possible to take enough fentanyl to override the blocking effect of buprenorphine and still overdose, but this is uncommon. We very commonly do see overdoses after short-short buprenorphine treatment, i.e. the short Suboxone script mentioned above, or after a detox episode. This brief period of ineffective "treatment" reduces tolerance dramatically, making it extremely dangerous to go back to fentanyl or other opioid use after the protective effect of buprenorphine wears off. This is why we see a transient 7x increase is overdose-related death rates after a short period of lost tolerance, such as after a period of incarceration or detox without a plan for ongoing treatment afterward.

Have you found many negative long-term issues beyond relapse? I kicked an opiate addiction in the early 2000s without Medically Assisted Treatment, but have found that even today I cannot tolerate opiates. Not only do I get sick, when I stop I begin withdrawal all over. I had a brain surgery 2 weeks ago with only Tylenol.

Do Suboxone users see this? And how has this impacted your care of people with Substance Use Disorders? Do you advocate for MAT?

Thanks for everything you're doing. As a social worker, these are the programs I see work.

That sounds adaptive! Congratulations on your long-standing recovery, and thank you also for sharing your experience with others through your work as a social worker. In my experience, I find that patients who have been on Suboxone effectively in the past with no intolerance, almost aways will continue to tolerate the medication well when there's a need to resume it. I've not observed any sort of acquired intolerance, at least not in sufficient numbers to suspect it's at all common. I have known many patients who are in stable, successful remission of their opioid use disorder, or their tobacco use disorder, to experience revulsion or even nausea, sometimes sweats or hives, when in the presence of a strong trigger or the drug they've previously moved on from. I think this likely has to do with the strong emotional association between the trigger and the pain that the drug previously caused, when the person has moved beyond the positive, euphoric feelings that were once associated with that drug use. I can only speculate though. I do advocate strongly for use of medication for opioid use disorder (MOUD), previously referred to commonly as MAT. Effective, appropriate use of these medications is what's going to turn the corner on the opioid crisis. The need is just incredible.

I've been a patient with Bicycle Health for the past five months. I really cannot sing the praises of this group enough. Using Suboxone has allowed me to resume my life with absolutely no cravings for opiates. Now with that said, I would like to ask what are the general steps for a person who has stabilized on Suboxone and who now wants to start the process of getting off the drug completely?

I can't say how much I appreciate your trust in our program. There's a really good editorial that describes discontinuation of care for opioid use disorder that I think says it better than I'm able: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2019.19121245

The long and short of it is that many folks understandably look for an end to treatment, a point where you can say you're recovered and can be done. What we find, very consistently is that patients have a very strong tendency to return to old habits following discontinuation of medical treatment for OUD. Not always immediately, but eventually, often during times of grief or stress which come up eventually for everyone. These rates are close to 100% when treatment is stopped within a month, 50-80% when stopped within a year, and stay consistently above 50% even after 18 months of treatment. And the consequences of a return to illicit use, "relapse," are often devestating, so best practice, not just for our program but all high-quality addiction medicine programs, is routinely not to recommend stopping care. That said, just like a very small percentage of patients can successfully control their blood pressure with exercise and weight loss, with diligence and a lot of support, patients who strongly wish to move toward stopping medical treatment sometimes can. That process looks like first assessing the social causes or prior illicit use and anticipating possible triggers for return to use, and making sure those are very well-addressed in a stable, sustainable way, then developing a plan to slowly taper down the medication, being attentive for risk factors that may pop up, until discontinued. Upon discontinuing buprenorphine, there is another medication called naltrexone (Vivitrol) that is a long-acting monthly injection that can prevent overdose in the event of a return to illicit use, but it's not an opioid at all like buprenorphine so can feel more liberating for some patients.

I’m a pharmacist at an independent retailer. Within the past year or so, our local clinic, which uses buprenorphine for opioid addiction, began prescribing (concurrently with suboxone) amphetamines (adderall), benzodiazepines (usually klonopin) and gabapentin almost universally to its patients. Two board-certified addictionologists oversee the clinic’s operations.

Am I missing something? Is there a place for multiple scheduled substances in treating opioid addiction? Or, if not for addiction, is it reasonable to use these medications so liberally in this population? My impression is that this practice is ensnaring a large patient population susceptible to developing addiction to ensure the clinic’s long-term viability.

If this practice is wholly inappropriate as I truly believe it to be, what is the best course of action? Should I notify the board of medicine? I’d feel like a snitch. Also, isn’t someone reviewing prescribing practices?

Not OP, but this may be a "safe supply" approach. We're doing the same thing because the supply lines of illicit substances has been so disrupted due to covid that it's often safer to just prescribe people a safe supply of these meds then have them continuing to use illicit substances off the street.

We had a bunch of unexpected ODs and ER visits last year related to tainted benzos and tainted crack. Quite a few clients have managed to kick their crack/cocaine addiction with prescribed stimulants, which some may argue is just replacing one addiction for another but the damage done from inhaling fentanyl laced crack is def worse than taking addies. Everyone we've given safe supply benzos to haven't had any other unexpected results show up in their drug tests either, just what we're prescribing instead of the mishmash of random substances and designer drugs they used to have. No ER visits or ODs in our client population since we took this approach and quite a few have had great success getting more structure in their lives (less crime, less sex work, less homelessness), so we're calling it a win so far.

ETA: there isn't really much evidence to support this approach and no decent guidelines. it's definitely not standard practice but the concept is gaining steam in addiction medicine. It's more of a desperate times call for desperate measures situation, don't want anyone getting the idea that this is recommended or a normal thing.

I haven’t considered that. I can appreciate that this could be an unconventional yet pragmatic approach with real-world benefits. Thanks for the insight.

that's a lot of additive risk. My practice is to prescribe a medication when there's a good reason to expect it will benefit a specific condition, and harm potential is less than benefit. I can imagine a scenario where it would be appropriate to prescribe all 5 of those medications for a limited period of time, but I've never run into that situation in reality and have cared for a lot of folks with opioid use disorder.

I abused opioids in my 20s. Now in my 30s I find myself occasionally using them again.

Now I use opioids to feel normal emotionally, and to have energy. Is there such a thing as being naturally low in producing endogenous opioids? Is there a treatment for this?

Wow that's an interesting question. I'm not aware of any inherent, or genetic, endogenous opioid deficiency condition. I think it's worth considering that opioids themselves have no primary effect at all on the body or mind (that we know of) Their effect is completely dependent on activation of the opioid receptor, which then causes a series of direct and indirect effects in the body. So when considering where someone's "normal" opioid homeostasis, or set-point, level is, we don't look at the amount of opioid in the body but the relative level of opioid receptor activation compared to that person baseline level of activation. A person who uses opioids frequently will actually have fewer, and much less responsive, opioid receptors than others as the body is working to adapt to the super-high amount of opioids typically present - So in the withdrawal state, the baseline level of activation is so high (because of tolerance), that a "normal" state of activation for a non-tolerant person is truly a severe opioid deficiency for that person. We know this severe opioid deficient state last 3-7 days after stopping exogenous opioid use before the body starts to adapt to the new, more normal set-point, by increasing receptor numbers and sensitivity again, but some residual level of deficiency (usually felt as fatigue) often continues for months. What that opioid receptor activation level looks like decades later has never been studied, but we do know that return to problematic use, even decades later, has a strong tendency to devolve very quickly into every-day habitual use, so ongoing support, trigger avoidance, a plan in the event of developing risk of return to problematic use, is important lifelong.

I know for a fact that is can be longer than 3-7 days and that the constant vomiting, uncontrollable diarrhea and insanity causing restless leg syndrome can last past the ten day mark. An intake coordinator at a detox who said this was impossible and as a result turned me away because I said I was on day 5. Said I would be fine soon enough. But I was only getting sicker. He said that I must have used me recently. But I hadn’t. I was I dry heaving into his garbage pale as he told my mother that I’d secretly gotten high more recently or was faking my symptoms. We left in utter shock. I realized after that I should of just lied and been like sure I used 2 days ago, let me into detox. But I’d been trying to cold Turkey and was proud of what I’d managed to endure and could t believe the situation.

24 hours later my mother dragged me into the ER again. I was unconscious and had very large bedsore from tossing and turning so quickly nonstop and the friction that were just pouring blood. Nurses rain to me thinking I’d been in a car accident. When my mother told him I’d gone cold Turkey they wondered why on earth she’d not brought me in sooner. She told him we were there yesterday, and that Clem the detox intake coordinator had said I was faking. My mom was told that they would be having a serious discussion with him and his superiors. I ended up, not in detox, but in hospital for another 8 days. A hospital that releases pregnant woman the same day they give birth. I was seriously I’ll. I transferred to a rehab facility on top of a mountain where our dorms were at the bottom of a hill. The first day I collapsed in the snow trying to make it to the morning meeting. I’d lost consciousness and laid in the snow over 2 hour before someone found me and I had frost burns on my face for almost the entirety of the 28 day program.

Peoples bodies are different. Also what people have access to can be drastically different. I’d been getting 3 grams a day from my best friend with a key, before it went out to people to get stepped on. As pure as heroin that makes it to the states gets. #4. And I’d had a completely uninterrupted supply for years and years. Never once coming close to any stage of withdrawal, never even not high as a kite.

That’s going to be a huge difference to somebodies tolerance than a junkie that is stealing what he can when he can and driving an hour into the projects, getting vastly different product on the day to day that’s been cut to garbage and sometimes probably gets beat and spend a night sick. I knew addicts that spent many hours sick every single day. That’s got to result in less dependence.

Doctors should know that there can be unusual cases. I suffered needlessly when I decided I couldn’t cold Turkey and needed medics assistance. Had organs shutting down from dehydration.

Being turned away from care in this situation is beyond awful. Yes, everyone is different, and what you experienced is more severe than the average episode of withdrawal but without a doubt possible. The failures of our medical system, especially around addiction care, are inexcusable, and I'm sorry you experienced that.

How does your care differ from in person? Can you share with us a success story of someone who went through treatment with your program?

It's more accessible than in person. Not sure where you're writing in from, but in the US only about 22% of persons with opioid use disorder access treatment for it. A big component of this is that it's very hard to find a provider who provides the treatment, and providers are usually clustered in urban areas. Telemedicine offers access regardless of how far folks live from their qualified doctor. There are also privacy and stigma concerns surrounding access to treatment; many with OUD who do have potential access to care don't access that care because they feel ashamed by doing so, especially in smaller towns where there's little anonymity in public places or even in your doctor's office. We've done extensive surveys and qualitative research studies that seek feedback on patient experience, and while the medical treatment itself is very similar or the same as in-person treatment, patient consistently report higher satisfaction rates and have a higher likelihood of continuing in care when it's via telemedicine. We have hundreds of success stories. One of my own patients described a history of feeling completely on edge of losing his relationships, his job, even his home, due to his expenses from obtaining street oxycodone (which is actually fentanyl). While he hadn't yet lot everything, he was headed in that direction and felt like he couldn't talk to his primary care doctor about what was going on because he had an image of general success, still having a home, a family, a job, even though it was in danger. the way he described his experience was that it was a tremendous relief, and it was astoundingly simple compared to the way recovery is often described in the media. He regained stability, normalcy, confidence, and financial security within about 4 months of beginning care. He stopped smoking too, added bonus :)

Here's a verbatim success story from one of our patients who has agreed to allow us to share it anonymously:

"At some point about 10-15 years ago, between my back pain and dental pain, I’d intermittently been on opioids. Then I had a kidney stone, and a doctor wrote a huge prescription for opioids, and I ended up hooked after that. I was on and off with opioids for many years. Then my mom got diagnosed with ALS (Lou Gehrig’s disease), and I finally decided to try to stop. I went through withdrawal when I eventually stopped, and things got pretty bad. I got online to try to figure something out, some kind of remedy to curb the withdrawal effects. I found Bicycle Health, talked to my mom about it, then went ahead and tried it.
That was my life, trying to keep pills on-hand, making sure I knew where to get more pills before I ran out. At times when I’d run out, it was no good. It affected my life at home with my family in a really negative way. At work, I wasn’t a very good worker when I didn’t have pills, and when I did have them, there were negative effects as well. I made really good money while working throughout those 10-15 years, but I have nothing to show for it because of my opioid habit.
Now that I’m on Suboxone, I can function. I function normally. I’m not high anymore. I can think right. I sleep better, eat better, feel better. I’m bettering myself in every way. I have a pile of savings… I’m actually saving money now. I pay my bills. I don’t need to borrow money anymore.
I live with my mother and grandfather. He’s 91 years old… he has hearing problems, vision problems, and COPD. My mom has ALS. When I’m not working, I take care of my mom full-time. When you called, I just got done making her dinner.
I’m ecstatic about telehealth… this way I’m able to do all my appointments from home. It’s just so much easier and more convenient this way. I don’t know where I’d be without Bicycle Health. It’s great, it’s really great. I couldn’t ask for a better way to get the help I need."

- Joel (not a real name, pseudonym selected by the patient)

How does buprenorphine work ?

It's helpful to understand how other opioids like oxycodone or even heroin work to understand how buprenorphine works. Opioids bind to and strongly activate a protein in the body called the mu opioid receptor. Strong activation of this receptor causes euphoria, and very strong activation cases overdose and death. Weak periodic activation is a normal part of the response to stress, pain, and other normal processes. Part of opioid withdrawal is caused by tolerance, where a person who uses opioids often becomes adapted to very strong opioid receptor activation, so normal weak activation becomes inadequate to feel normal, so instead you feel pain, depression, fatigue, in the absence of any opioid. Buprenorphine is a very long-acting weak opioid receptor activator, and it also blocks the receptor against strong activation. So it suppresses withdrawal, restoring a feeling of normalcy, and protects against overdose by blocking full activation of the receptors

Idk if I'd call it "weak" bc it's strong af kicking off all the other opiates off the receptors and replacing them. There is just no "high" or euphoria

Agreed! It binds very strongly to the receptor, thus preventing other opioids like heroin or even fentanyl, at the right dose, from having much effect. And while blocking it strongly, it doesn't activate it fully so results in a normalization of withdrawal without causing euphoria or sedation.

What is the best way to approach an addicted friend, to get help?

One of my favorite resources, both for medical providers learning about opioid addiction, and also for patients and families (I have no affiliation or financial interest in this organization), is the PCSS Project at pcssnow.org

We know that being confrontational typically isn't helpful and can undermine a relationship. Rather, creating space for a person to talk about something that's bothering them, can lead to a real productive conversation that may result in a shared decision to take a step toward addressing that problem. There's a framework called motivational interviewing that described this approach to having a productive conversation about opioid use:

https://pcssnow.org/resource/motivational-interviewing-talking-with-someone-struggling-with-oud/

PCSS has pretty extensive additional resources that describe the various next-steps, once you and your loved one have agreed that they have some motivation to seek care.

https://pcssnow.org/resources/resource-category/community-resources/

Is providing addiction services on a for-profit basis superior to other models?

No, absolutely not. Academic medical centers and hospital systems, as well as federally qualified health centers, free clinics, and some other medical entities, operate as not-for-profit organizations, and the large majority of clinics, private offices, and medical groups, use the for-profit tax designation because they must. Either type of program can be fantastic or can be terrible. Right now, I see the most promising innovation in OUD treatment coming from programs outside of academia and the not-for-profit world. That's not to say that may not shift again in the future.

Question about your proof: you appear to have just posted your linkedin profiles, did you mean to put a status referencing the AMA? As it stands, anyone could have linked your profiles. So the only proof is a picture of one of you, which seems like less than I would hope for.

Happy to share a bit more proof. Here's a link to a status update on LinkedIn about the AMA, which tags myself and features a comment from me about the AMA https://www.linkedin.com/posts/bicyclehealth_iama-riama-activity-6844608687080775680-uitp/

I also have this photo https://drive.google.com/file/d/1nk4PPAOJBJTZM5U1PkFm5KD4TcNEwcgX/view?usp=sharing

which hopefully looks enough like my LinkedIn photo to match. Certainly always open to answering more questions about my background though

Seems the photo link provided might not be correct. try this one which should be shared publicly:

https://drive.google.com/file/d/1nk4PPAOJBJTZM5U1PkFm5KD4TcNEwcgX/view

I’ve been on around 200mg of Methadone a day for over 6 years. I’ve been considering tapering down to get off it and my clinic is suggesting going down 5mg every 1-2 weeks til I get to 30mg a day then stopping for several days and switching to subutex. What are your thoughts on Methadone maintenance long term and the best way to get off it? Is switching to subs after getting to 30mg a viable option to minimize withdrawals in your experience? I have heard from many other people that the withdrawal from Methadone can last months compared to other opiates. This has really kept me from continuing my taper out of fear of withdrawing. Any input is appreciated!! Thanks!

Methadone has been around for, gosh, well over 50 years now, and is an effective treatment for opioid use disorder. the current opioid crisis would be much worse than it is without the availability of methadone, BUT, and this is a big but, the regulations surrounding it's use are extremely onerous. It's use for addiction treatment is limited to opioids treatment programs ('methadone clinics') which can be patient-friendly, pleasant places, but much more commonly are not, and continuing to fulfill the strict requirements of these programs is often very burdensome to folks in long-standing remission of their OUD who are doing very well and would like a less burdensome form of care. So it sounds like, you find your care to be effective but are looking for a setting that's more compatible with your life. This is a tough situation to be in, because reducing a methadone dose does take a very long time, months to years, and can put long-term remission at risk if withdrawal reemerges during this process, which it will if done too quickly. That said, yes, the plan you've described is a normal, recommended process for transitioning from methadone to buprenorphine. In my own practice, I will usually begin with 5-10% dose decreases every 2 weeks, and will slow down or temporarily stop if this results in withdrawal or other risk to the patient, then I tweak the schedule accordingly to try to meet the patient's timeframe goals as best we can while minimizing risk. If done cautiously enough, there could be little or no withdrawal, but the critical factor there is knowing when to slow down, knowing when to stop the decreases, knowing when to maybe even go back up a step until you're feeling ready to continue.

What is your experience / your clients' experiences with Iboga treatment?

Very limited I'm afraid! Use of Iboga, traditionally is an involved cultural ritual, and there's more to it than just the substance that could potentially contribute to beneficial effects. Even the substance is a mix of many chemical compounds rather than a single or limited number of active substances that can be easily studied (or easily patented to motivate pharm companies to conduct studies). So I hear patient stories, and personal stories of Iboga use. It sounds terrifyingly uncomfortable throughout the ritual, then some folks have a period of feeling enhanced well-being for a time afterward, and others don't. This may have to do with variability in the purity of the substance or the ritual, or variability in the way certain people metabolize or respond to it. I know it can cause dangerous adverse effects in some cases including heart failure, and nervous system toxicity. So it's impossible to say with any accuracy what the risk/benefit profile of the substance is. Since we do have effective and safe, well-studies treatment options for OUD available, I don't recommend use of Iboga due to all the unknowns and the likelihood of harm that exceeds benefit.

Here's a link to a helpful abstract, but the full-text is behind a paywall:

https://pubmed.ncbi.nlm.nih.gov/30216039/

It's important that if you or anyone is considering traveling internationally for an Iboga ritual, you make sure you don't have other risk factors for heart disease that could further increase your risk of an adverse event or death. This can be done through your primary care doc or GP. I know it can be awkward to have that discussion if you don't already have a trusting relationship and feel able to talk about drug use, but given the potential severity of the heart toxicity, it's a crucial safely step.

Do you take medicare and other insurance plans with historically low poor reimbursement rates for the service providers?

medicare yes. we're trying to contract with insurers including medicaid programs as broadly as we can. It's an insanely long, tedious process. I just spoke with a doc who's received funding for an innovative program to improve primary care access to medicaid patients across about 10 states, and no joke, they're spending their first 15 months of time working on medicaid contracting before medical services can even begin.

I'm a physician, and this year's X waiver requirement being, well, waived, is helping a lot of people access MAT that wouldn't have easy access otherwise. Do you think this may be the end of the X waiver?

It's the end of the extensive training requirement to get the initial X-waiver to treat 30 patients, so now all you have to do is submit a notice to SAMHSA that you'd like a 30-patient X-waiver, and it will be granted. That's permanent. I sincerely hope to see the complete end of the X-waiver system, but my hope has no predictive value for the future :)

Is there any good/proven method to stop using Suboxone? I used to be addicted to heroin I've now been sober for over 6 years. I only take 1mg of Suboxone a day but getting rid of that last bit seems harder then anything.

The last milligram is often the hardest, and fatigue can stick around for weeks or even months after dropping from 1 to 0. When a patient has difficulty with that last step, I recommend making it a series of smaller steps. Sometimes this looks like dropping from 1mg a day to alternating 1mg and 0.5 mg every other day for 2 weeks, then 0.5mg every day for 2 weeks, then 0.5mg every other day for 2 weeks, then 0.5mg every 3rd day for 2 weeks, then off. So instead of going from 1 to 0 in a day, this does it over 2 months.

What sort of experience do you and Bicycle Health have and/or treatment options do you offer with regards to dependence and addiction involving opiate analogs and opiate-like substances such as kratom, especially in the concentrated extract forms that have much more potential for abuse and addiction, and that seem so widely and easily available at many gas stations and convenience stores?

Being a program that practices broadly, across 23 states now, we have extensive experience working with kratom, and more recently tianeptine use disorder. These substances activate the mu-opioid receptor and will lead to opioid tolerance, withdrawal, and often addiction like other opioids. They both have extensive other effects though, activating many chemical pathways in the body which can effect people in very different, often unpredictable ways depending on their unique metabolism, genetics, and other substances they might be using. Tianeptine has a potent anti-depressant effect, so when this drug is taken is very high amount each day due to development of addiction, opioid withdrawal isn't the only problem than develops upon stopping it. There's also an anti-depressant withdrawal that buprenorphine will not address, so often depression and fatigue will be severe even when the opioid withdrawal itself is treated. There's not much available in the way of formal studies that teach us exactly how to handle this situation, but many of our addiction specialist providers have used other anti-depressants off-label, sometimes temporarily, other times indefinitely when there's a real depressive disorder in addition to the substance use disorder. So far this seems to be helpful. Our tianeptine and also kratom patients generally do well once this initial period of more-than-expected discomfort resolves.

It's frustrating to see these hazardous substances sold at smoke shops and gas stations. Information is key to making sure they're not purchased unknowingly, and lead to dependence. States and the FDA can be slow to act when a novel compound is commercialized; we'll see tianeptine disappearing from most store shelves very soon. Kratom will likely be longer-lived since the substance has advocacy and lobbying groups supporting it, but there's no medical indication for the substance and there is very real harm potential.

How does your virtual clinic manage to monitor usage to prevent diversion? Urine drug screens, strip counts, etc?

I frame that question as, 'How do we create systems of accountability that help patients meet their goals for successful treatment?' Everybody has moments of weakness and can be vulnerable to a slip. Sometimes in such a moment, the only reason a person may have not-to-use is feeling some sense of accountability to a program of drug use monitoring. So yes, we provide random urine drug screens, saliva drug screens, run-out date tracking, and medication counts for two reasons: 1. help patients stick to their treatment plan, and 2. get objective info about the effectiveness of treatment. So if/when a patient does return to illicit use, if they don't tell us we still want to identify that sooner rather than later so we can modify treatment to be more effective. That can look like a dose change, identifying the relapse trigger and addressing it, or offering additional behavioral health support, or all 3. Sometimes situations arise where a person may not truly have any treatment goals, and may actually be trying to mislead us to profit by selling medication. Our program also identifies and addresses this issue when it comes up.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800751/

Is it true that Naltrexone works to curb alcohol cravings in addition to opiates?

Yes, the naltrexone injection has good evidence that it helps patients with alcohol use disorder (AUD) to reduce the amount of alcohol they consume. It has a very clear role in care of patients with alcohol use disorder.

It gets complicated when opioid use disorder (OUD) is also part of the picture because naltrexone is less effective for OUD when compared to buprenorphine (Suboxone) or methadone, and you can't use it at the same time as buprenorphine or methadone. So when OUD and AUD exist together, I try to determine which is more severe, and I recommend the best available treatment for the more severe condition, and the second-line treatment for the other.

What one MAT-oriented practice (or policy) do you feel could best serve the well-being of patients if enacted nationally in the US?

Medical providers in the US need to obtain a special registration, the X-waiver, to prescribe buprenorphine (Suboxone) for opioid use disorder. The X-waiver system creates an exception to the 'Narcotic Addict Treatment Act of 1974,' which otherwise prohibits use of the 2 most effective treatments for OUD outside of opioid treatment programs (OTPs, or 'methadone clinics'). This half-century old law is a badly outdated piece of legislation that prevents us from effectively addressing the opioid crisis. The waiver system is a workaround to it that allows some highly motivated providers to offer this treatment, but many providers prefer not to address opioid use disorder in their practices, and for these providers the need for an x-waiver can be a convenient excuse to avoid providing the service. It also prevents insurers and health systems from effectively requiring providers to offer appropriate services for OUD. If the X-waiver system goes away, that normalizes OUD care, bringing it in-line with other routine and expected care for common chronic conditions. It enables health systems to create quality standards and incentivize providers to inform themselves and provide effective OUD treatment rather than referring to specialty programs (like ours) that provide the needed service. That'd be the most impactful, realistic short-term change that I'd like to see.

sorry, just to clarify I mean eliminate the x-waiver system AFTER creating a permanent piece of replacement legislation that is aligned with modern medial knowledge and permits appropriate treatment for OUD without unnecessary barriers.

How do people without resources obtain opiods? I've always wondered this. Who gives it to them, and how do they pay for it?

There are 2 main sources, licitly-produced opioids that are purchased, traded, or stolen (diverted) from their legal source, and illicitly produced opioids. Patients who fill prescriptions for opioids may sell, trade, or lose a portion or all of the prescription, and opioids can also be stolen or illicitly sold from pharmacies, hospitals, and manufacturers. Heroin and fentanyl, specifically, can also be produced in labs or, in the case of heroin, poppy farms. These labs used-to be generally small-scale, but by now have facilities and production capacities that can rival pharmaceutical companies since fentanyl has become such a widely available and profitable illicit opioid.

Opioid habits can be very expensive, costing thousands or tens-of-thousands of dollars each month, but can also be relatively cheap in certain areas with wide availability, costing as little as $10 per day ($300 per month) to obtain cheap heroin. Folks who are very under-resourced are often savvy enough to obtain this amount of money to sustain a habit that they're unable to stop. Panhandling, trading services, through generosity of friends, lots of ways.

What do you guys think about prescribing klonopin with bupenorphine?

clonazepam (Klonopin) is a benzodiazepine, a type of sedative, that can helpful in certain limited situations. It has a clear role in severe grief reactions, when a loss creates so much stress than a benzodiazepine can help a person avoid even further loss in the short term due to that stress. It's also useful in treating alcohol withdrawal, which is a brief but very dangerous condition that can be lethal if not treated appropriately. Benzodiazepines, like opioids, lead to tolerance/withdrawal and often an addiction if taken on an ongoing basis, and folks who already have a substance use disorder like opioid use disorder are at heightened risk of developing addiction from other habit-forming substances. So, there is a potential short-term role in very clearly defined situations, but there's also substantial risk involved so it should be avoided whenever possible

Do you ever treat patients with Kratom addiction? The stuff is somewhat controversial, I know. There is a subreddit called r/QuittingKratom . What are you opinions on it.

I must have been typing a prior answer to a very similar question while you were asking this one :) Copying the following prior response. Please do ask any follow-up question it doesn't address:

Being a program that practices broadly, across 23 states now, we have extensive experience working with kratom, and more recently tianeptine use disorder. These substances activate the mu-opioid receptor and will lead to opioid tolerance, withdrawal, and often addiction like other opioids. They both have extensive other effects though, activating many chemical pathways in the body which can effect people in very different, often unpredictable ways depending on their unique metabolism, genetics, and other substances they might be using. Tianeptine has a potent anti-depressant effect, so when this drug is taken is very high amount each day due to development of addiction, opioid withdrawal isn't the only problem than develops upon stopping it. There's also an anti-depressant withdrawal that buprenorphine will not address, so often depression and fatigue will be severe even when the opioid withdrawal itself is treated. There's not much available in the way of formal studies that teach us exactly how to handle this situation, but many of our addiction specialist providers have used other anti-depressants off-label, sometimes temporarily, other times indefinitely when there's a real depressive disorder in addition to the substance use disorder. So far this seems to be helpful. Our tianeptine and also kratom patients generally do well once this initial period of more-than-expected discomfort resolves.
It's frustrating to see these hazardous substances sold at smoke shops and gas stations. Information is key to making sure they're not purchased unknowingly, and lead to dependence. States and the FDA can be slow to act when a novel compound is commercialized; we'll see tianeptine disappearing from most store shelves very soon. Kratom will likely be longer-lived since the substance has advocacy and lobbying groups supporting it, but there's no medical indication for the substance and there is very real harm potential.

Is your statement "Bicycle Health, the leading provider of virtual opioid addiction treatment" your opinion or a fact?

I caught that mistake and edited to "a leading provider," or at least tried to at the start of the AMA. I'm a Reddit newb and apologize if the original version is still showing. Certainly opinion. I think we do good work, and so do colleagues in other programs. We have several practices that I do think are the best in the field, and other practices that aren't. Always working to improve.

Why would anyone in their right mind trust corrupted pharmaceutical companies after all they have done to us and all the times they have lied to us?

I wouldn't trust a single source. I do my diligence, evaluating a broad variety of trials and other evidence from different sources. Pharmaceutical company initial trials are useful to kick-start other studies and to give us initial information on dosing and adverse effects, but with awareness, in interpreting the results, that the investigators have a financial incentive to prove something specific.