Opioid use drives dopamine release, leading to opioid use disorder.
When a person uses an opioid to get high, such as heroin or fentanyl, the mu opioid receptor is stimulated repeatedly by opioid drug molecules. Initially, there is a dopamine deluge, with levels much higher than normal.
After repeated use, the opioid user develops a substance use disorder, where the brain has established new dendritic pathways in the reward center, reinforcing the need for more opioids. Dopamine levels tend to be low at this point, so the person must continue opioid use to get levels back to normal.
In the midst of this dopamine drama, the person develops an opioid dependence, reinforced by both addiction and a physical dependence. If they stop using opioid drugs, they experience fatigue, depression, cravings, and various physical symptoms, such as restless leg syndrome, muscle cramps, and chills.
A medication assisted treatment medication, such as Suboxone (buprenorphine/naloxone), helps to restore dopamine levels to near-normal. In addition to blocking withdrawal symptoms, Suboxone prevents cravings associated with low dopamine levels.
How does Suboxone work as a reward deficiency syndrome treatment?
Reward deficiency syndrome is a term coined by pharmacologist and research scientist, Dr. Richard Blum. The condition describes a state where a person’s dopamine levels are low, caused by an addiction.
The addiction could be to a chemical substance or a behavioral dependence, such as gambling, sex, porn, social media, or gaming. The addicted person is compelled to persist in the addicting activity to boost dopamine levels.
With persistent exposure to a stimulus that invokes a pleasure response by triggering a dopamine rush, the dopamine baseline goes down. This is the brain’s natural response to over stimulation.
When the baseline levels of dopamine are low, events that would normally provide pleasure in the course of everyday life are no longer pleasing. For example, activities such as eating delicious food, playing with your children, enjoying a sunny day, are no longer as enjoyable.
Normally, the brain responds to positive daily activities with increased dopamine delivery. However, the neurons of the central nervous system are no longer able to provide enough without the stimulation of the preferred addictive activity.
Suboxone provides a boost to the dopamine baseline.
If Suboxone contains an opioid, how is taking Suboxone different from taking any other opioid? Is Suboxone treatment simply a matter of trading one addiction for another?
Interestingly, buprenorphine, the partial opioid agonist in Suboxone, is different from other opioids in how it interacts with opioid receptors. Buprenorphine is both an opioid receptor antagonist, a blocker, and a partial agonist, which means that it only partially activates the receptor.
How does the unique action of buprenorphine distinguish it from opioids such as heroin, fentanyl, oxycodone, and other opioids of abuse? Those other opioids are full agonists and are not blockers, so they bounce on and off opioid receptors repeatedly, causing an over stimulation of the dopamine system.
Buprenorphine, on the other hand, binds to opioid receptors, blocking and partially activating. This results in a steady dopamine boost that elevates the baseline levels to near normal.
As a result of Suboxone’s unique mechanism of action, patients feel normal, as if they never had an opioid addiction. Long-term treatment with Suboxone helps the brain to heal from addiction, rather than continuing to fuel the fire of addiction with the dopamine surges of full-agonist opioids.
What happens to reward deficiency syndrome after long-term buprenorphine treatment?
During a year or more of buprenorphine therapy, the patient’s brain has time to heal from the effects of addiction. However, there is still a physical dependence on the buprenorphine itself.
This dependence may be partially related to a downgrading of dopamine receptors. Now that the patient has moved past opioid addiction, it may be time to taper buprenorphine gradually, giving the brain a chance to adjust to less opioid stimulation and a chance to naturally increase dopamine deployment.
If the patient quits Suboxone cold-turkey, or tapers too quickly, they may have a worsening of reward deficiency syndrome. They feel depressed, anxious and tired, without much motivation to get anything done.
While the patient typically will not experience opioid cravings, they will not appreciate the fact that they suffer from opioid withdrawal when they cut back on Suboxone. Quitting Suboxone can be as difficult as quitting any other opioid, due to the physical dependence issue.
For most patients, the secret is to go very slowly on tapering. Also, tapering to as low a dosage as possible will help to make the transition easier.
Are there supplements, medications, or therapies that can help with Suboxone withdrawal and reward deficiency syndrome?
The completion of Suboxone therapy, including gradual tapering, buprenorphine withdrawal support, and the final drop-off, are not covered in MAT training courses. Doctors are taught how to put someone on Suboxone, but not how to get them off.
Patients are aware of the lack of an end-game plan from the beginning. When doctors do not address the plan for completing therapy, even if it is after a year or more of treatment, patients are more hesitant to get started.
Another issue is that the manufactured buprenorphine/naloxone sublingual tablets and films are not well-designed for gradual tapering. SAMHSA, and other government agencies involved in oversight of the addiction treatment pharmaceutical industry, should insist on dosage forms of the medication that support tapering.
For example, they should make a wider variety of dosages to help patients with a more gradual step down. Additionally, they should design the tablets and strips to be divided easily into smaller, equal pieces.
In addition to gradual tapering, there are other therapies that may help. Research has shown that hyperbaric oxygen therapy (HBOT) can ease the symptoms of withdrawal during and after tapering.
Medications such as Lucemyra, and others, work to reduce Suboxone withdrawal symptoms. Of course, additional medications increase the risk of side effects, so doctors must be cautious in prescribing medication to attenuate withdrawal.
Additionally, there are supplements that support increasing levels of dopamine in the central nervous system. It may be helpful to utilize these supplements to ease the transition to Suboxone-free living.
Can a pro-dopamine regulator, such as KB220 or KB220z help with reward deficiency syndrome by boosting dopamine levels during Suboxone tapering?
There are a variety of supplements that claim to improve neurotransmitter levels in the brain. In my podcast interview with Dr. Teralyn Sell, Dr. Sell recommended utilizing supplements that “filled the buckets” with precursors of neurotransmitters.
The idea is to make the dopamine building blocks available to the brain rather than the neurotransmitter itself. It’s like the famous quote about teaching a man to fish rather than feeding him fish for a day.
If dopamine could be provided directly to the brain, it would respond by producing less of the neurotransmitter, which would be counterproductive. By taking a supplement that supports the brain’s efforts in ramping up dopamine production, transitioning through drug withdrawal can be somewhat smoothed over, with less discomfort and better functioning.
A supplement known as KB220, or KB220z, has been used to study the effects of supporting dopamine production in the central nervous system. This product contained various amino acids, herbs and other natural substances, such as passionflower, astragalus, aloe vera, and white pine bark.
This particular formulation was manufactured by Cepham. There may be other supplement products with similar ingredients that are supportive of the brain’s increased production of dopamine to reduce opiate withdrawal symptoms.
Are there activities that can help to overcome reward deficiency syndrome?
It is definitely possible to increase dopamine levels naturally with a variety of physical activities. Some people feel that when they are sick with Suboxone withdrawal during the tapering process, that it is best to stay in bed and sleep it off, but this is not the best way to approach tapering-related withdrawal symptoms.
While it is not easy to get motivated to stay active during those periods of Suboxone reduction where withdrawal symptoms return, it is important to push through. Staying active will help to boost dopamine levels, reducing the severity and length of adjustment periods when the Suboxone dosage has been further cut back.
For people who enjoy working out in the gym, strength training has been shown to boost dopamine levels. You may not feel like working out, but once you get started, you will immediately begin to experience the benefits of weight training in overcoming reward deficiency syndrome.
Other activities include aerobic exercise, walking, dancing, yoga, Pilates, jumping rope, Tai Chi, and many others. Your chosen activity does not have to be excessively strenuous to benefit.
If the thought of starting a new activity during Suboxone tapering seems overwhelming, simply commit to taking a short walk outside every day. You can gradually increase the distance of your walk, as tolerated.
Is it possible to ever feel normal again after quitting opioids?
There are people who believe that long-term opioid abuse can lead to permanent opioid receptor damage. They think that it is impossible to ever feel normal again without taking an opioid.
While it is true that recovery from protracted withdrawal can take a long time for some people, it is possible to feel normal again. For some people, it may be days to weeks. For others, it could be months to several years.
Fortunately, it is rare for a protracted withdrawal syndrome to last significantly longer than a year. In most cases, the time to near-complete recovery is in the weeks to months range.
If you are going through a protracted withdrawal period after quitting opioids, or completing a long-term course of Suboxone therapy, you should have hope for the future. The human brain is resilient and can heal over time.
Engaging in positive activities, avoiding further opioid use, and taking healthy supplements that support brain health will help to get through withdrawal faster and with less severity. By sticking with a long-term recovery program, it is certainly possible to feel normal again and to live a happy and fulfilling life without opioids.
