I attended the American Society of Medicine Annual Conference in San Diego the weekend of April 13, 2018. Much of the focus of the conference was on new  information about addiction and its treatment. Here are some tidbits:

  1. Drug dealers and addicts can contaminate virtually any substance with dangerous drugs. Commonly adulterated are CBD oil and vape fluid for e-cigarettes. Frequent additives include dangerous analogs of K2 spice and MDMA, which can be lethal. Fentanyl is not far behind. Avoid these substances and don’t allow addicts to bring liquid substances into treatment.
  2. A well-done controlled trial in Europe shows that tramadol may work as well as buprenorphine for opiate detox, with the added benefit that patients don’t then have withdrawal symptoms from tramadol like they do after even a quick buprenorphine taper. The usual cautions apply: this was just one study, and tramadol is a controlled, Schedule IV opiate. So using it for opiate withdrawal in the U.S. runs into the federal prohibitions of the Harrison Act, which makes it a crime to use opiates to treat opiate addiction (except for methadone maintenance and Suboxone).
  3. The FDA recently came out with a statement that although there are overdose risks when buprenor­phine is taken with illicit benzodiazepines or alcohol, the life-saving benefits of buprenorphine are so powerful that this risk must be assumed and buprenorphine continued.
  4. Fentanyl doesn’t respond substantially differently to buprenorphine than other illicit opioids. Treatment is the same.
  5. Gabapentin and pregabalin (Lyrica) are drugs of abuse. They’re occasionally taken by themselves (especially Lyrica) but more often are used to augment the high from other drugs. Certainly no opiate addict should leave a rehab with a prescription for gabapentin.
  6. We all know not to endorse patients’ plans to keep drinking after leaving rehab when dependent on other drugs (even when they insist “Alcohol is not my problem!”). Now it’s clear marijuana and other cannabinoids have the same concern: a greatly increased risk of relapse.
  7. I spent a lot of time asking experts and drug company scientists, “How long do opiate addicts have to take your drug for them to achieve a stable recovery?” Nobody knows for sure. Vivitrol is typically used for a year or a little more, but that’s because that’s how people use it, not because anybody has any data. Most people will relapse back on opioids if they stop methadone maintenance or Suboxone prematurely; duration of needed treatment is years.