Our substance abuse treatment program is designed for opiate addicts whose goal is abstinance rather than maintance.
Patients usually begin Subutex at the time of their first visit.
Pre-program treatment consists of stabilization on Suboxone and assessment of psychiatric and psychosocial needs
Our program consists of an entry level motivational group followed by a relapse prevention group
Wake Forest Psychiatric Associates emphasizes groups to treat addicitions. Groups offer to patients what teams offer to athletes, an energizing effect that can help patients realize their goals. Our entry level group focuses on motivation which ultimately is the fuel that propels patients towards their goals. Our continuation group focuses on relapse prevention and preparation to get off of Suboxone.
We realize that successful emergence from an opiate addiction can be a complicated business and that patients may wish to be involved with our program for variable lengths of time. Patients will be encouraged to continue until their confidence and preparation assures stability.
Our Philosophy
Getting clean is a pleasure seeking enterprise
Success is dependent on motivation and preparation
Durable abstinance happens to those who discovers life's natural highs, and have the confidence and strength to shape life in ways that provide fulfillment.
In deciding to begin treadment, patients are embarking on what feels like a very uncertain road. They are giving up drugs but creating a temporory void when they do so. No one wants to 'run on empty' for very long, and it is our business at WFPA to help patients experience as soon as possible that the void created by giving up an addiction is filled with something better than anything addiction could ever supply. Unfortunately, there is no quick fix to a substance abuse problem, and often there is a period of time during which the patient feels depleted and discouraged. This is why our program is highly motivational. We sincerely believe that the patients we accept into the program can make it, but at the same time are realistic in admitting that the road can be difficult. If we were coaching an athlete who wanted to be a winner, we would tell him the same thing.
Addicts need to be aware of their strengths and particularly their liabilities. We believe that as diverse as all patients are, the weakness that threaten success encompass relatively few behavioral dimensions, and we are prepared to address and treat these dimensions.
A significant problem for patients is impulsivity. By this we mean either a tendency to too quickly give into urges or conversely, to panic too easily under duress. It is important to master impulsivity not only to conquer drugs, but also to make progress in building a life.
In addition to impulsitivity, addicts frequently face an additional challenge. Science teaches us that an addict's brain can become over time less sensitive to ordinary pleasures. So in the early aftermath of abusing you are likely to feel blah about things that ought to be exciting. This can lead to a feeling of emptiness and discouragement, and have a demoralizing effect on recovery efforts. The good news is that this state is temporary, and ones sensibilities do begin to perk up in the early months of recovery.
It is our firm belief that your recovery will be a highly rewarding process, though these rewards can take time to become a reality. For this reason, faith in the possibility of a good outcome is an important motivator. Our treatment approach is grounded on the belief that recovery eventually leads to a net increase in enjoyment of life. During the period of your recovery we will do everything possible to help you realize these benefits as early as possible.
Counseling
Counseling uses behavioral and motivational tools to deal with a behavioral and motivational problem
Effective counseling is central to substance abuse treatment. As part of their addiction addicts subject themselves to powerful behavioral conditioning that reinforces using. In everyday terms they have develop a bad habit. There are myriad subtle mechanisms that reinforce habitual behavior. Behavioral conditioning is well illustrated by the famoust example of Pavlov's dogs. Pavlov, in a series of experiments conditioned his dogs to salivate when they heard a bell. He did this by coupling the sound of a bell with the delivery of food. Later when the food was uncoupled from the bell, the dogs reacted to the bell's ring with all of the inate physical responses one would expect a dog to have if they were in fact being presented with a meal.
Addicts use behavioral terms such as 'trigger' to describe things and situations that provoke an urge to use. But these triggers can be quite subtle and can baffle even the cleverist patients. One of our patients once told us that he found it inconvenient to carry around his Suboxone all day long in his pocket because the tablets were fragile and tended to break. When we asked why he would carry them since the drug only needs to be taken once daily he chuckled as he realized that there was no good reason, it was just an old habit from his abusing days. What is unfortunate is that such 'old habits' are powerful reinforcers of addiction. Barely visible to the patient, they act like multiple threads of a pschic cobweb, binding the patient to his old habit. For the patient to experince a stable revovery, each thread must be identified and peeled away.
Counseling is also useful in helping patients energize and sustain the necessary motivation to enable them to create and carry out plans to build a life that supports recovery. Research teaches us that there are a number of reasons why this is so. We know that, either because of a predisposition, or because of the effects of sustained drug abuse, addict's brains have weakened motivational and reward circuits. Addiction blunts a person's capacity to fully enjoy ordinary rewards. To the extent that this deficit in enjoymennt is a toxic reaction to exposure to drugs, time is a great healer, though it can take months for an addict's brain to normalize and allow the patient to fully enjoy the natural highs of living. Counseling during this discouraging period is a helpful way to sustain morale.
Finally, research points to the importance of building a good life as a necessary ingredient to recovery, and counseling is well suited to help a person in this enterprise. In experiments conducted in the 70s, Alexander was able to show that rats living in a rewarding environment, in this case an ideal 200 sq. ft habitat he named 'rat park', were much less likely to abuse drugs than rats living in traditional cages. He hypothosized that in standard lab cages the rats were understimulated and were driven to use drugs by their deprivation and despair. To the extent that patients feel their lives are a cage, their recovery prospects are diminished. So a significant component of recovery involves the necessary reshuffling of a person's like to make it more rewading.
Buprenorphine Use of Buprenorphine frees patients from the daily preocupation of needing to obtain drugs
Tapering off of buprenorphine is not a free ride but with preparation and support it is only a hurdle, not a barrier
Reevaluating you attitude toward pain and discomfort can be liberating as you finnally let go of painkillers
Buprenorphine (Suboxone, Subutex) is an opiate with mixed agonist/antagonist properties. This means that buprenorphise is a real opiate but has properties that moderate its effects making it safer and less abusable than methadone. In our experience patients who are addicted to opiates can rapidly switch to buprenorphine and be comfortably stabilized within days.
Buprenophine is available in either of two sublingual forms. Suboxone is the most widely used and consists of buprenorphine bound with the antagonist, Naltrexone. The idea of adding the later compound to the formulation is to make the drug less tempting to divert. When taken the tablet to dissolves under the tongue, and little or none of the Naltrexone is absorbed and the patient enjoys the full effect and benefit of the medicine. If on the other hand, the drug is diverted and attempts are made to crush or otherwise adulterate the tablet, the buprenorphine is contaminated with Naltrexone and the medication is rendered ineffective.
Buprenorphine is a not a treatment for opiate dependence, rather, it is a tool that allows patients undergoing substance abuse treatment to be less preoccupied with their physical comfort. It thus simulates the experience of being drug free so that patients can then begin to adapt to a drug free life style. Buprenorphine is very long acting and needs be taken only once daily. When the dose is properly adjusted, patients have no sense of withdrawal or otherwise needing the drug between doses.
Because of its mixed antagonist properties, it is somewhat surprising that patients so quickly become comfortable switching to buprenorphine yet it works without being intoxicating. Buprenorphine tightly binds to the brain's opiate receptors but doesn't 'tickle' them much, the way street drugs do. For this reason, most of the work of withdrawal occurs during the maintenance period the patient is on the drug without the patient being aware it is happenning.
Nevertheless, getting off of Buprenorphine is a significant task, accompanied by a mild to moderate degree of discomfort. It is very important that patients prepare themselves psychologically for the taper. To insure success, there needs to be a high degree of motivation and a proper mind-set toward discomfort. We should explain what we mean by the latter.
It is our experience that many opiate addicts have hang ups about pain. It's not that they tolerate pain less well than the average person. Rather, the addict's experience of pain is often complicated be feeling affronted by it. We try to help patients develop broader attitudes toward pain beyond simply thinking that because it hurts, it is bad.
When first thinking about pain in this way patients often ask, 'who wouldn't a person be affronted by something as obnoxious as pain?' But consider that many people accept pain as a part of their experence. To the athlete pain in training is a sign that the exercise is pushing the athlete to the limit where improvement in strength or speed occurs. To the mountain or rock climber, coping with pain is a part of the experience that is included in their sense of achievement.
Getting off of bupnenorphine is uncomfortable, but by no means unbearable. Having a perspective that the pain encountered during the taper is a challenge to be mastered rather than an evil to be avoided, not only increases the chance of a successful taper, but encourages an attitude toward adversity that will serve a person for a lifetime.
In our program patients begin their taper when they feel ready and remain in the group for at least 8 sessions after their taper. We do expect and encourage patients to complete their taper within six months of starting the program. Once the taper begins, it takes place over a four week period. During this time patients decrease their daily dose once weekly by 25% of the original starting dose. Any significant withdrawal discomfort will be managed by supportive means including, if necessary, non-opiate medications such as Clonidine.
Financing
Wake Forest is a fee for service practice that does not participate on insurance panels. Information about the cost of treatment can be had by contacting our practice.
We ask that patients bring to our program a high lever of committment to succeed. Getting clean should and needs to be your highest priority. In order for patients to succeed they must have the necessary time and financial resources to fully participate in our program. As part of this committment, we ask that patients at the time of signing into the program make a deposits for a portion of the program expenses. We provide more information about treatment financing in our section on fees and financing (see sidebar).