Outpatient Medical Assisted Treatment (MAT) Detoxification
Any type of addiction can be both harmful to the patient and their loved ones. Such addictions can even become life-threatening. We approach each patient with care and understanding. The good news is that effective and caring medication assisted treatment can help a person recover. Dr. Locketz is a specialist in outpatient drug detoxification. He treats addictions to prescription pain killers such as Percocet, Oxycontin, Vicodin, Lortab, Ultram, Morphine, and Dilaudid. In addition, he treats addictions to alcohol and benzodiazepienes such as Xanax, Klonopin, Valium, Ambien, and Ativan. Dr. Locketz treats addiction to nicotine as well.
DR LOCKETZ INTERVIEWED BY KSTP ANCHOR KEVIN DORAN ABOUT MAT WITH SUBOXONE
GOALS FOR MEDICATION ASSISTED TREATMENT (MAT)
- Prevent or decrease the chance of medical complications of withdrawal.
- Provide as much respect, comfort, and anonymity as possible for the addicted patient.
- Prepare the patient to do recovery work in order to maintain abstinence from illicit drugs.
Learn more about medication assisted treatment by clicking the topics belowSuboxone Medical Detoxification
What does our program consist of?
Suboxone (buprenorphine / naloxone) is a medication approved for the office based treatment of opiate (e.g. Heroin) and opioid (e.g. oxycodone, Percocet, Vicodin, Lortab) addictions. It is several generations better than its predecessor methadone. Suboxone can be thought of as a much safer, more convenient, and discreet alternative to methadone maintenance (a good analogy is iPod vs iPhone) Patients receive a prescription which can be filled at any pharmacy just like other types of medications. In Suboxone (buprenorphine / naloxone) maintenance, the medication is taken at home as a daily dose in place of the opiate or opioid being abused. A stable dose is maintained, in contrast to the cycle of tolerance with escalating doses for the same effect, withdrawal symptoms in between doses, and drug seeking behavior for the opiate or opioid being abused.
In medically supervised withdrawal, a long acting form of a medication that is in the same class as the drug being abused is given until withdrawal symptoms are alleviated. The medication is then given in doses that are gradually tapered down. This allows for a more humane form of detox.
Suboxone is an excellent medication for the outpatient detoxification from narcotic painkillers such as oxycodone and Percocet. It is considered to be very safe, with a low risk of overdose. Suboxone is also unique in that in order to start the medication, the patient has to be somewhere between early to moderate withdrawal. If the medication is started too early, it will cause precipitated withdrawal, which is more severe than regular withdrawal.
Dr. Locketz uses a number of medications to make patients more comfortable overnight before they start Suboxone the next day. Clonidine is an old blood pressure medication that treats symptoms such as sweats, chills, and shakes. He also uses the class of medications called benzodiazepines, such as Klonopin, Valium, and Ativan. These alleviate anxiety and insomnia, which are usually a big part of the withdrawal syndrome. Hyoscyamine is also a great medication prescription medication for abdominal cramping and diarrhea. Phenergan is another medication that tends to work very well for nausea and vomiting.
How many times a month do they need to follow up with us in clinic or telemedicine? 3-4 times a week/3-4 times a month?
Once a patient is induced on Suboxone and is stable we see them monthly. This can be accomplished via Telemedicine every other month or at one of our satellite location. We require laboratory monitoring of compliance with our program for which we need an oral fluid swab every other month.
On the other hand, some patients choose to not go on Suboxone maintenance. Their goal is to do a medical detox off of Oxycontin or heroin and remain opioid or opiate free. A number of physicians believe that this second option is not advisable. They believe that all patients should go on Suboxone maintenance for an extended period of time.
Dr. Locketz does not agree that all patients require extended periods of maintenance. Instead, he chooses to customize the medication assisted treatment plan to each individual patient.
Is counseling required and is it included in the $1000 consult fee and $500 follow up fee?
Psychotherapy using motivational interviewing and cognitive behavioral therapy (CBT) for substance abuse. These have been shown to be very effective in the treatment of opioid, opiate, benzodiazepine, and alcohol addictions. Motivational interviewing is a non-confrontational style of addiction psychotherapy where the patient is guided to find their own internal motivation for change. CBT is based on social learning theory. which states that drug and alcohol use are learned behaviors. Because drug and alcohol use are learned behaviors, they can therefore be “unlearned”. CBT for alcohol and drug addictions is also based on the findings that inaccurate or biased thoughts and beliefs, coupled with poor coping skills, lead to drug and alcohol abuse. CBT teaches changes in thinking about, and reactions to, relapse provoking situations. It requires practice and time to effectively use the principles of CBT. In CBT, a lapse or relapse is not used as a punishment. Instead, they are used as a learning tool towards your ultimate goal of abstinence or moderate alcohol use.
Dr. Locketz also facilitates referral and entry into various forms of recovery treatment such as SMART Recovery® and Intensive Outpatient Treatment (IOP) at local addiction treatment centers such as internationally known Hazelden. He offers non-12 step help with alcohol and drug addiction treatment. When inpatient drug and alcohol addiction treatment is warranted, Dr. Locketz will facilitate entry into an inpatient facility.
One hour of initial Face-to-face or Telemedicine Counseling/Psychotherapy is included with the initial fee.
What are the distance requirements whether or not people are eligible for telemedicine?
Our goal is to help the patient through a recovery path. To that end most patients have internet access and can leverage Telemedicine in their recovery. We are expanding our services rapidly and hope that we will have better access in the Northern MN area soon for those patients who simply ca not afford a computer or have limited internet access.
How long are they on the $500/month maintenance fee for Suboxone?
This will vary from patient to patient. We require a six month commitment for most patients.
Previous medical records required?
We prefer to have the medical records the day of the first visit. We will await patiently their arrival after this visit if they are not available.
DETOXIFICATION: Alcohol detoxification is medically supervised withdrawal. Medically supervised withdrawal is accomplished by giving a long acting drug that works on the same receptor system as alcohol. The drug is given in tapering doses down over a period of a few days to a week. The class of drugs called benzodiazepines are used for outpatient detox from alcohol. I like to use Librium, as it is a very long acting. It continues to taper itself down after the medication is stopped due to it’s long half-life. Also, alcohol and Librium are both sedatives, so caution must be used, as combining the two can result in overdose.
DO I ACTUALLY NEED DETOX?: Many patients come to their first appointment asking for detox. Frequently, after doing a history and exam with vital signs, we find that detox is not needed. Alcohol withdrawal is diagnosed for the most part by hand tremors, abnormal vital signs (elevated heart rate and elevated blood pressure), feeling generally ill, anxious, and irritable. In order to develop a withdrawal syndrome, the body needs to have a physical dependence on alcohol. With physical dependence, a characteristic withdrawal syndrome will develop as the blood alcohol level progressively goes down to zero. Physical dependence to alcohol develops when a person drinks throughout the day and evening. Many of the patients that come to see me only start drinking after work. They do not drink during the day, so they do not become physically dependent on alcohol. Isolated complaints of anxiety and irritability are not symptoms that require treatment with a Librium taper. These symptoms do require treatment with other types of medications, which do not have the risk of overdose when combining a benzodiazepine with alcohol in the event of a relapse
ALCOHOL WITHDRAWAL IS A SERIOUS MEDICAL CONDITION: Alcohol withdrawal should be taken very seriously and treated with caution. The first and most important reason for detox is to try and prevent life and limb threatening complications. Two life-threatening complications of alcohol withdrawal are grand-mal withdrawal seizures and delirium tremens (“DT’s”). Delirium tremens is alcohol withdrawal with hallucinations and unstable vital signs. Outpatient medical detox from alcohol is not safe for everyone. If you are interested in outpatient detoxification from alcohol, Dr. Locketz will assess your safety for this type of treatment. Please note that the first appointment is an evaluation only. Medications are never prescribed at the first appointment. Please also note that you must stay with a responsible adult friend or family member for the first 24 to 48 hours of your detox. That person will be administering your medication to you.
STOP OR MODERATE YOUR DRINKING: There are now a different number of medications that are available to help people reduce or stop their drinking.
GABA DRUGS: Baclofen / Neurontin / Topamax / Campral
Drugs that affect the GABA system in the brain can be very effective for the treatment of alcoholism. One of the receptors that alcohol stimulates is the GABA-A receptor. Stimulation of the GABA-A receptor is responsible for the calming and anti-anxiety effects of alcohol. Sedative medications such as Valium also stimulate the GABA-A receptor. In fact, alcohol can be thought of as liquid Valium, and Valium can be thought of as freeze dried alcohol.
So far, baclofen is the most effective GABA medication that I prescribe for alcohol addiction. I continue to be amazed by how effective this medication is for many people who identify themselves as alcoholics or heavy drinkers. Many patients who start baclofen describe a complete loss of cravings, as well as a complete indifference to alcohol. About half of the patients for whom I prescribe baclofen stop drinking completely within the first few days of starting the medication. Other patients significantly reduce their drinking to a healthier level. I have found it to be helpful for some patients who want to comfortably moderate their drinking. They control the alcohol, the alcohol does not control them.
Baclofen is actually a muscle relaxant that has been around for a long time. It works for the treatment of alcoholism in two ways. First, it treats anxiety by acting on the GABA-B receptor. Second, baclofen attenuates the brain neurotransmitter dopamine, which is responsible for the euphoric and rewarding effects of alcohol. GABA-B receptors and dopamine receptors in the reward pathway of the brain are intertwined. This gives baclofen a very unique mechanism of action, and is the reason such dramatic results can be seen when treating patients who identify as alcoholics or heavy drinkers.
Baclofen basically works by treating anxiety and emotional states of tension and stress. In my medical practice, I treat many high functioning people with stressful jobs who will not drink during the workday. However, drinking will start almost immediately when the workday is over. The alcohol (“liquid Valium”), provides relief from the anxiety, tensions, and stressors from the day. Baclofen works by treating these symptoms without the intoxication of alcohol. With this type of biological treatment for alcoholism, patients are able to stop or reduce their drinking, while feeling good at the same time.
Neurontin is a seizure medication that is also used for chronic pain, anxiety disorders, and addiction to alcohol. Neurontin can be thought of as working at the GABA-A receptor. Like all GABA drugs, Neurontin essentially works to put alcohol addiction into remission by treating anxiety and emotional states of tension and stress. So far, I have found Neurontin to be the second most effective GABA drug that I prescribe. Neurontin is prescribed as a medication to be taken three times daily, and it is also taken as an as needed medication for cravings. Neurontin can also be taken as a prophylactic dose for “high risk” situations, such as work or social functions where many people will be drinking. If being able to drink socially is the goal for treatment, some patients are able to moderate their drinking with the help of Neurontin.
Topamax is a seizure medication that is also used for weight loss, migraine headaches, and addiction to alcohol. It works at the GABA-A receptor, so it works for alcohol addiction by treating anxiety and emotional states of tension and stress. Topamax also works at glutamate receptors, which are increased in people that are alcoholic or heavy drinkers. Glutamate is a neurotransmitter that is excitatory, so an excess of glutamate contributes to feelings of anxiety and irritability. Topamax can be thought of as blocking the effects of glutamate. Topamax is taken as a nightly or twice daily dose, and a steady blood level of the medication is achieved within a few days.
Campral was specifically developed and FDA approved for the treatment of alcoholism. It acts at GABA-A and glutamate receptors. I have found Campral to be the least effective of all of the GABA drugs. This is ironic, as it is one of the few medications that was created and FDA approved specifically to treat addiction to alcohol.
NALTREXONE AND THE SINCLAIR METHOD
One of the receptors that alcohol stimulates is the mu-opioid receptor. This is the same receptor that is stimulated by narcotic pain medications such as Percocet and Vicodin. Activating this receptor causes a release of dopamine in the brain. Dopamine is a neurotransmitter that is responsible for feelings of pleasure, reward, and euphoria. Naltrexone is a medication that is a mu-opioid receptor antagonist, meaning that it blocks the receptor. If a person drinks while taking this medication, the alcohol will have a much less pleasurable effect.
In the United States, naltrexone is prescribed as one 50mg tablet that is to be taken every day. At the same time, patients are told to completely abstain from alcohol. With the Sinclair Method, developed and widely used in Finland, naltrexone is prescribed in a different way. Patients are told to continue drinking as they normally would. At the same time, they must always take one 50mg tablet of naltrexone one hour before drinking Just as important as the one hour rule. the naltrexone must never be taken on non-drinking days. The main goal with the Sinclair Method is to achieve the process of extinction for cravings for alcohol. With extinction, when a behavior which was pleasurable and positively reinforcing, becomes less pleasurable and less positively reinforcing, the behavior gradually and naturally stops occurring. This gradual process eventually leads to less cravings and less desire for alcohol. The goal with the Sinclair Method is to eventually enable people to either stop drinking or to moderate their drinking.
I have found the Sinclair Method to be the most effective way to use naltrexone. The actress Claudia Christian used the Sinclair Method to put her alcoholism into remission. She then founded the C3 Foundation to provide education, support, and resources for use of the Sinclair Method. The C3 Foundation can be found at www.cthreefoundation.org. “One Little Pill”, a documentary movie about the Sinclair Method, and narrated by Claudia Christian, can be found at the C3 Foundation website as well.
Dr. Locketz also facilitates referral and entry into various forms of recovery treatment such as SMART Recovery® and Intensive Outpatient Treatment (IOP) at local addiction treatment centers. He offers non-12 step help with alcohol and drug addiction treatment. When inpatient drug and alcohol addiction treatment is warranted, Dr. Kloda will facilitate entry into an inpatient facility.
Dr. Locketz is very skilled in the outpatient drug detox from benzodiazepines such as Xanax, Klonopin, Ativan, and Valium. Detoxification from benzodiazepines can be particularly difficult for patients. The anxiety and other symptoms associated with benzo withdrawal can be tremendous.
A successful benzodiazepine detoxification requires a slow taper, a close therapeutic relationship between the physician and the patient, as well as regular office visits and phone follow-ups.
Dr. Locketz’s overall success rate with benzodiazepine detoxification is due, in part, to his ability to treat anxiety disorders and pain. His philosophy is to always tailor the treatment to each individual patient.
Addiction Psychotherapy involves using motivational interviewing and cognitive behavioral therapy (CBT) for substance abuse. These have been shown to be very effective in the treatment of opioid, opiate, benzodiazepine, and alcohol addictions. Motivational interviewing is a non-confrontational style of addiction psychotherapy where the patient is guided to find their own internal motivation for change. CBT is based on social learning theory. which states that drug and alcohol use are learned behaviors. Because drug and alcohol use are learned behaviors, they can therefore be “unlearned”. CBT for alcohol and drug addictions is also based on the findings that inaccurate or biased thoughts and beliefs, coupled with poor coping skills, lead to drug and alcohol abuse. CBT teaches changes in thinking about, and reactions to, relapse provoking situations. It requires practice and time to effectively use the principles of CBT. In CBT, a lapse or relapse is not used as a punishment. Instead, they are used as a learning tool towards your ultimate goal of abstinence or moderate alcohol use.