PAC 330 Module 4 Opioids Example

The Shot or the Strip? Opioid Pharmacology, the Fentanyl Wave and Choosing Between Naltrexone and Buprenorphine

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 330: Substance Abuse

Instructor Name

Month Day, Year

The Shot or the Strip? Opioid Pharmacology, the Fentanyl Wave and Choosing Between Naltrexone and Buprenorphine

Jake is twenty-nine and works on a roofing crew in Omaha. Six years ago he broke his ankle in a fall and was prescribed oxycodone. When the prescription ended, he bought pills, then switched to heroin because it was cheaper, and for the past year he has used fentanyl daily. Last spring a friend from his crew died of an overdose. Jake walked into Prairie Hope one Monday and told his counselor he wanted help but had heard two different things: a coworker swore by the monthly naltrexone shot, and his cousin takes buprenorphine strips. He wanted to know which was better. This paper profiles opioids and plans his treatment. Jake and Prairie Hope are fictional, while the studies are real.

How Opioids Act

Kosten and George (2002) described the neurobiology of opioid dependence. Opioids bind to opioid receptors, especially the mu receptor, throughout the brain and body. In the reward system, they increase dopamine release, producing euphoria. In the brainstem, they slow breathing, which is how overdose kills. With repeated use, receptors adapt, and tolerance develops: higher doses are needed for the same effect. When opioids are stopped, the adapted brain rebounds. The authors emphasized the role of the locus coeruleus, a brainstem area that produces norepinephrine. Opioids suppress its activity; with chronic use, it adapts by increasing activity, and when opioids are withdrawn, it becomes overactive, producing anxiety, sweating, rapid heartbeat, aches and other withdrawal symptoms. The misery of withdrawal is seldom life-threatening, but it is a powerful reason to keep using.

Tolerance has a dangerous consequence. After a period of abstinence, such as detoxification, a hospital stay or incarceration, tolerance falls, and a person who returns to their previous dose can overdose.

The Three Waves

Ciccarone (2019) described the American opioid overdose crisis as three overlapping waves. The first, beginning in the late 1990s, involved prescription opioids, driven by aggressive marketing and liberal prescribing. The second, beginning around 2010, involved heroin, as efforts to restrict prescribing pushed some people toward a cheaper, more available illicit supply. The third, beginning around 2013, involved illicitly manufactured fentanyl, a synthetic opioid many times more potent than heroin, increasingly mixed into heroin, counterfeit pills and other drugs. Ciccarone argued that supply factors, especially the spread of fentanyl, drove the steep rise in deaths in the third wave. Jake's path, from pills to heroin to fentanyl, follows the three waves.

Comparing Medications

Three medications are approved for opioid use disorder. Methadone, a full agonist, and buprenorphine, a partial agonist, activate opioid receptors, preventing withdrawal and reducing craving. Naltrexone, an antagonist, blocks opioid receptors, preventing opioids from having an effect; an extended-release injectable form is given monthly.

Lee et al. (2018) compared extended-release naltrexone with buprenorphine-naloxone in the X:BOT trial, which randomly assigned adults with opioid use disorder at inpatient detoxification programs. A key difference emerged at the start. Naltrexone can only be given after a person has fully withdrawn from opioids, typically after a week or more, because giving it earlier causes sudden, severe withdrawal. Many more people assigned to naltrexone failed to start it than people assigned to buprenorphine-naloxone, which can be started during withdrawal. In the full sample, relapse was more common in the naltrexone group, largely because of these induction failures. Among people who successfully started their assigned medication, relapse rates were similar.

What Jake Knows About Fentanyl

Jake knows more about fentanyl than most textbooks. He knows that the pills sold as oxycodone in his neighborhood are pressed fentanyl, that the strength varies from batch to batch and that his tolerance protects him only until it does not. His friend died after a week in jail, when his tolerance had fallen. Jake's counselor treated this knowledge as expertise and asked what had kept him alive so far: never using alone, testing a small amount first and keeping naloxone in his truck. These are harm reduction practices, and acknowledging them builds trust and gives the counselor a starting point for a plan that keeps him safe while he decides about treatment.

Overdose Education and Naloxone

Naloxone reverses opioid overdose. Walley et al. (2013) compared Massachusetts cities and towns that had started programs to train people who use opioids, their families and friends to recognize and respond to overdose and give them naloxone. Where such programs operated, fewer people died of opioid overdose than in similar places without them, and the more widely a community distributed naloxone, the larger the drop. Naloxone is now recommended for anyone at risk of opioid overdose and for the people around them.

The Plan

Jake's counselor and the program's prescriber explained the options and the X:BOT findings. Jake was drawn to the monthly shot because he liked the idea of not taking a daily medication, but he was worried about a week of withdrawal before starting it, which he had never managed before. He chose to begin buprenorphine, with the option of switching to the monthly buprenorphine injection or, later, to naltrexone. His prescriber will begin buprenorphine when he is in moderate withdrawal, measured with a withdrawal scale. Jake, his girlfriend and his mother will receive naloxone and training. He will attend weekly counseling focused on his triggers on job sites and his grief for his friend. If he later chooses naltrexone, the switch will be supervised to avoid the dangerous gap in tolerance.

Conclusion

Opioids act on receptors that control both pleasure and breathing, and tolerance makes the period after abstinence especially dangerous. Kosten and George explain the pharmacology of dependence and withdrawal, Ciccarone describes how fentanyl transformed the crisis, the X:BOT trial shows that naltrexone and buprenorphine work similarly once started but differ in how hard they are to begin and Walley and colleagues show that naloxone distribution saves lives. Jake's informed choice of buprenorphine, with naloxone and counseling, reflects that evidence.

References

Ciccarone, D. (2019). The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis. International Journal of Drug Policy, 71, 183-188. https://doi.org/10.1016/j.drugpo.2019.01.010

Kosten, T. R., & George, T. P. (2002). The neurobiology of opioid dependence: Implications for treatment. Science & Practice Perspectives, 1(1), 13-20. https://doi.org/10.1151/spp021113

Lee, J. D., Nunes, E. V., Novo, P., Bachrach, K., Bailey, G. L., Bhatt, S., Farkas, S., Fishman, M., Gauthier, P., Hodgkins, C. C., King, J., Lindblad, R., Liu, D., Matthews, A. G., May, J., Peavy, K. M., Ross, S., Salazar, D., Schkolnik, P., ... Rotrosen, J. (2018). Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): A multicentre, open-label, randomised controlled trial. The Lancet, 391(10118), 309-318. https://doi.org/10.1016/S0140-6736(17)32812-X

Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., Ruiz, S., & Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ, 346, f174. https://doi.org/10.1136/bmj.f174