WellStep blog

In our Alcohol Treatment Program, WellStep Atlanta, located in Roswell, Georgia, utilizes Vivitrol (naltrexone) as one of several medications that help reduce alcohol cravings. Since Vivitrol is still relatively new and not very familiar to most people, some information on this drug is provided here:

What is Vivitrol? Vivitrol is an injectable form of naltrexone, an opiate blocker, that has a one month duration of action.
What is Vivitrol used for? According to the official prescribing information, “Vivitrol is indicated for the treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL. Patients should not be actively drinking at the time of initial Vivitrol administration ” In other words, Vivitrol is designed for patients who still have cravings after stopping drinking. (Vivitrol has also shown to reduce the number of “heavy drinking days” so the medication may be effective for “binge drinkers” as well.)
How does Vivitrol work? From the official prescribing information: “The neurobiological mechanisms responsible for the reduction in alcohol consumption observed in alcohol-dependent patients treated with naltrexone are not entirely understood. However, involvement of the endogenous opioid system is suggested by preclinical data." In other words, how Vivitrol works is not entirely understood. But scientists feel it may affect the “reward system” by working as an opiate blocker, so that alcohol does not produce the same pleasurable action as previously.
Where is this shot given? The injection is intramuscular and is given in the gluteal area.
Who cannot take Vivitrol?
Patients with acute hepatitis or liver failure
Patients receiving opioid analgesics
Patients with current physiologic opioid dependence
Patients in acute opioid withdrawal
Any individual who has failed the naloxone challenge test or has a positive urine screen for opioids
Patients with an allergy to carboxymethylcellulose, or any other components of the diluent
Is Vivitrol expensive? Yes, however most health insurance plans appear to be covering Vivitrol at the moment.
For more information on Vivitrol, visit www.Vivitrol.com . For specific questions on how Vivitrol is used at WellStep Atlanta, please visit www.WellStep.com or www.Atlanta-Alcohol-Treatment.net

In our Alcohol Treatment Program, WellStep Atlanta. located in Roswell, Georgia, utilizes Vivitrol (naltrexone) as one of several medications that help reduce alcohol cravings. Since Vivitrol is still relatively new and not very familiar to most people, some information on this drug is provided here:

What is Vivitrol? Vivitrol is an injectable form of naltrexone, an opiate blocker, that has a one month duration of action.
What is Vivitrol used for? According to the official prescribing information, “Vivitrol is indicated for the treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL. Patients should not be actively drinking at the time of initial Vivitrol administration ” In other words, Vivitrol is designed for patients who still have cravings after stopping drinking. (Vivitrol has also shown to reduce the number of “heavy drinking days” so the medication may be effective for “binge drinkers” as well.)
How does Vivitrol work? From the official prescribing information: “The neurobiological mechanisms responsible for the reduction in alcohol consumption observed in alcohol-dependent patients treated with naltrexone are not entirely understood. However, involvement of the endogenous opioid system is suggested by preclinical data." In other words, how Vivitrol works is not entirely understood. But scientists feel it may affect the “reward system” by working as an opiate blocker, so that alcohol does not produce the same pleasurable action as previously.
Where is this shot given? The injection is intramuscular and is given in the gluteal area.
Who cannot take Vivitrol?
Patients with acute hepatitis or liver failure
Patients receiving opioid analgesics
Patients with current physiologic opioid dependence
Patients in acute opioid withdrawal
Any individual who has failed the naloxone challenge test or has a positive urine screen for opioids
Patients with an allergy to carboxymethylcellulose, or any other components of the diluent
Is Vivitrol expensive? Yes, however most health insurance plans appear to be covering Vivitrol at the moment.
For more information on Vivitrol, visit www.Vivitrol.com . For specific questions on how Vivitrol is used at WellStep Atlanta, please visit www.WellStep.com

Many patients coming to our WellStep Atlanta for treatment have ongoing pain issues. Fortunately, buprenorphine(Suboxone/Subutex) can be very helpful in managing moderate to moderately severe pain. A new study published in the Annals of Emergency Medicine (November 25, 2011) found that for adults with acute bone fractures, a sublingual dose of buprenorphine relieves pain as effectively as intravenous morphine. Adverse effects were similar with both treatments, although more patients developed hypotension (low blood pressure) with morphine. Buprenorphine has been approved for pain management by regulatory agencies in many European countries and a buprenorphine patch now has an FDA indication for pain.

A study published this month in the Archives of General Psychiatry has shed some light on this question. In the study, entitled, “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial” , more than 600 treatment-seeking outpatients addicted to prescription opioids received Suboxone in combination with brief standard medical management, in which physicians evaluated treatment effectiveness and recommended abstinence and self-help participation. Results showed that approximately 49 percent of participants reduced prescription painkiller abuse during extended (at least 12-week) Suboxone treatment. The success rate dropped to 8.6 percent once Suboxone was discontinued. At WellStep Atlanta, we often prescribe Revia or Vivitrol (naltrexone), an opiate blocker, after patients are tapered off Suboxone . A waiting period of at least 10 days after discontinuing Suboxone is necessary before starting naltrexone. The use of naltrexone after Suboxone treatment has helped our patients tremendously in avoiding relapse through reduction of opiate cravings and blocking impulsive use of opiates.

 

The most popular treatment for opiate addiction (pain pill dependence) involves the use of buprenorphine (Suboxone or Subutex) to help patients comfortably detox from the addictive medications. Most patients choose to stay on Suboxone for over a few weeks. However,  while it is easier to come off Suboxone than most pure opiates, there are withdrawal symptoms from Suboxone even after only a few weeks unless the dose is tapered down very slowly.  Even when the Suboxone dose is reduced slowly, there are often some symptoms of anxiety, restlessness or cravings.

 

For patients not wanting to become dependent on Suboxone, WellStep Atlanta has developed a protocol for a unique one week detox program. Patients are prescribed low doses of Suboxone as well as medications to reduce anxiety, restlessness, aches/pains, and nausea. The most helpful medication is neurontin, a medication which is  FDA approved for seizure disorders but which is also useful for anxiety and restlessness. Zofran or phenergan may be used for nausea. Occasionally small doses of other anti-anxiety medications, such as chlordiazepoxide (Librium), are prescribed under closely monitored conditions for carefully selected patients. Medications to aid sleep such as Trazodone may also be prescribed.

 

Detox for opiate addiction using this new protocol requires that the patient not drive or operate  hazardous machinery. In addition, we recommend that patients take time off from work or school since they may still experience some withdrawal symptoms as well as sleepiness from medications.

 

In addition to the advantage of not becoming dependent on Suboxone, this protocol will allow patients to detox while saving on the costs of buprenorphine, a very expensive medication.

               For very heavy drinkers, stopping alcohol suddenly can cause a wide range of symptoms, from mild to life threatening, including seizures and delirium tremens (DT’s). Yet it is often very difficult to taper alcohol slowly, even with the anti-craving medication available today.

               Alcohol detox programs allow patients to discontinue alcohol completely and safely while controlling unpleasant withdrawal symptoms. This is done through the use of medications such as benzodiazepines (ie, diazepam and lorazepam) or through the use of carbamazepine (Tegretol), which is FDA approved for seizure control but very effective in controlling alcohol withdrawal symptoms as well.

               Most patients can go through alcohol detox on an outpatient basis, without the expense and inconvenience of hospitalization. However, other times hospitalization is necessary for closer monitoring and care. Factors that would favor outpatient alcohol treatment are: cooperative patient, able to be monitored 24/hours a day by a responsible adult, no severe, acute medical conditions, and no severe, coexisting psychiatric disorders. Factors that would weigh against outpatient detoxification are: uncooperative patient, lives alone with no close relatives or individuals available for monitoring, and acute or unstable medical and/or psychiatric problems. In addition, outpatient alcohol treatment is usually not warranted if there have been seizures, DT’s or other severe withdrawal symptoms in the past. If a patient is already in withdrawal, a withdrawal assessment scale (CIWA-Ar) is used by the clinician to help decide if the situation can be safely handled on an outpatient basis.

               At WellStep’s outpatient, office-based program, the patient comes in for an initial assessment and to be prescribed appropriate medications to get him or her comfortably through the next week without any alcohol. The patient is seen daily for at least 4-5 consecutive days for withdrawal and vital sign assessment and medication adjustments. A responsible adult is required to drive the patient and to stay with the patient at home during this time in order to call for immediate medical attention if necessary. After the detox period is complete, the patient will usually take medications that are FDA approved for alcohol cravings (ie, acamprosate and naltrexone) and begin counseling to learn techniques to stay sober and avoid relapse.

               Outpatient alcohol detox is safe, effective and low cost. For the majority of heavy drinkers who need alcohol treatment, this is a great way to start a successful recovery program. Please visit http://www.wellstep.com/atlantaalcoholtreatment.php for more information.

 

               At our new Atlanta Center for Adult ADHD, we utilize proven, effective medication for ADHD. In 2011, there are five medications which are FDA approved for Adult ADHD: Extended-release mixed amphetamine salts (Adderal XR), lisdexamfetamine (Vyvanse), OROS methyphenidate (Concerta), extended release methylphenidate (Focalin XR), and atomoxetine (Straterra). These are all long acting medications. 
               The first four medications are stimulants, which are generally felt to be more “robust” (more effective) than Straterra. However, Straterra would be preferable in cases of past stimulant abuse, when stimulants cannot be used for certain health reasons, and when the patient just does not want to take a stimulant class medication. Although Straterra takes 4-5 weeks to achieve a high enough blood level, it eventually provides 24 hour ADHD coverage.
               Bupoprion (Wellbutrin) is a non-FDA approved medication that can be used in many cases of ADHD when stimulants or Straterra cannot be taken.
               Stimulants can be divided into two groups, amphetamines and methylphenidate. 
               Adderal XR and Vyvanse are considered amphetamines and Concerta and Focalin belong to the methylphenidate class. Some patients do better with amphetamines and some with methylphenidate. Other patients do equally well with either medication. In my experience, amphetamines are better tolerated as far as side effects than methylphenidate so I usually start patients with an amphetamine class medication. Since there are many health conditions that would prevent safe use of stimulants, such as certain types of heart disease, abnormal heart beat, history of mania or psychosis, seizure disorder, untreated hyperthyroidism, untreated drug abuse, or glaucoma, it is important for you and your doctor to discuss all current and past medical problems before starting a stimulant. 
               Duration of action of the long acting stimulants varies in each patient. In general, Adderal XR lasts about 12 hours, Vyvanse lasts about 12+ hours, Focalin XR lasts about 10-12 hours and Concerta lasts about 10-12 hours. If longer action is needed, a short-acting stimulant can be added although insomnia can result from taking a stimulant to late in the day.                
               Since it is difficult to predict which stimulant will best improve the ADHD symptoms and have the least side effects, trying more than one medication is often helpful.

We are happy to announce the opening of the Atlanta Center for Adult ADHD at our Roswell office, offering state of the art medical and behavioral treatment for this condition. Dr. Banov is especially interested in ADHD and has participated in FDA regulated ADHD trials as a Clinical Investigator. Attention Deficit Disorder is a common condition among children and adolescents and has been diagnosed with increasing frequency among adults as well. Research shows that up to 60% of children with ADHD continue to have symptoms through adolescence and into adulthood. In addition, studies have shown that individuals with untreated ADHD have a much higher rate of substance abuse problems. Here at WellStep, we have seen a high rate of untreated ADHD in our patients being seen for substance or addiction problems. Symptoms of Adult ADHD can include difficulty paying close attention to details, making careless mistakes, finding it hard to organize activities or finish a task, having difficulty following instructions or conversations and being forgetful in daily activities as well as frequently losing things. Some adults with ADHD are quite restless and fidgety. ADHD diagnosis involves clinical evaluation, behavioral testing and the Quotient ADHD System, a computerized device that accurately measures motion and shifts in attention. The test takes 20 minutes for adolescents and adults. Treatment of ADHD usually involves medication, either stimulant (such as Dexedrine or methyphenidate) or non-stimulant (such as amoxetine). We also offer ADHD coaching and cognitive therapy. We look forward to helping many adults in the Atlanta area dramatically improve their quality of life with effective ADHD treatment at our new center.