I’d like to find an addiction specialist who will treat addiction to a mild opiate agonist. What is the best way to go about doing that? We’re not talking about hardcore opiates here; it’s a drug called tianeptine which has an affinity for the mu and delta opiate receptors about as strong as that of kratom. However, it works on more than one feel-good system—it also acts directly on the dopamine mesolimbic pathway, one of the brain’s primary reward circuits. It can be a very difficult drug to discontinue. The problem is that there is currently no treatment protocol for this substance. It just hit the market a couple of years ago and is sold through the Internet by companies which sell nutritional supplements and nootropics (‘smart drugs’). Despite the fact that it is legal and easily obtainable, it can be hideously addictive in susceptible individuals. Many long-term users report that it is more addictive than IV heroin or morphine. Right now the only information anywhere on the treatment of tianeptine withdrawal is anecdotal evidence from users. The only substance that almost everybody agrees will help is gabapentin. My regular doctor is completely unsympathetic to the problem and acts dismissively every time I bring it up. So I would like to find a practitioner who would be willing to prescribe me gabapentin, even if I have to pay for it out-of-pocket. Should I just make an appointment with an addiction specialist and hope for the best? Chances are that he or she would be familiar with the use of gabapentin for opioid withdrawal. Opiate users have been using it since the beginning of time. I’m just a little afraid to make an appointment, go in there, and just have him shrug his shoulders and tell me that he has no idea what I’m talking about. Any advice from somebody who’s been there? Feel free to ask additional questions for clarification; I’ll do my best to answer them.
Just looked into tianeptine, and egad, that’s a messy drug. Even so, I’d have to think buprenorphine would blunt the worst of the withdrawal. I’d be hesitant to use gabapentin (or its cousin pregabalin) along with buprenorphine, unless there were clear signs of clinical instability on the buprenorphine alone.
But I’m a pragmatic “in the trenches” primary care doc with decades of practical addiction medicine experience, and you’re unlikely to find a primary care doc such as me willing to go that road. I’d suggest going to see an addictionist or failing that, a licensed buprenorphine prescriber, and explain the situation, and see if you can come to agreement on some kind of protocol. You’ll need monitoring closely, and perhaps even a short inpatient stay, if things don’t go well as outpatient.
Gabapentin abuse is rising rapidly, and practitioners are getting leery about prescribing that these days too. There are more new psychoactive drugs out there than there are practitioners with experience in how to handle the resultant dependence and withdrawal for all of them. And I am no fan of all these so-called “smart drugs” either. We just don’t know what they do to the brain.
ETA: I’ve put a query out to a few select colleagues in the field on the topic, we’ll see if that garners any useful info.
Here’s how to find a buprenorphine prescriber:
Wow—I can’t begin to thank you enough. This gives me some real ammunition to work with. Users report that the worst of it is over in two weeks; it’s all downhill after that. So maybe I won’t require the inpatient stay. But I’ll get on this first thing tomorrow.
Ok, talked to my pal, a high powered psychiatrist and addictionist. And he concurs that’s one fucked up drug on a lot of levels, and there’s not a lot of experience in the US in dealing with it.
He advocates an approach of using some TCAs along with possibly some gabapentin or pregabalin, along with buprenorphine. Or maybe using naltrexone instead of buprenorphine and see just how habituated the opioid receptors really are before committing to opioids.
At any rate, he advises getting a doc who is either a psychiatrist who is also certified by the American Society of Addiction Medicine, or a psychiatrist who is also certified by the American Academy of Addiction Psychiatry. They’d have the credentials to untangle the serotonergic and opioid mess you’re in.
PM me if you like.
Thank you again; you’ve been of immense help. I’m going digest this tonight and make a decision tomorrow as to a course of action. I think my best bet is to make an appointment with an addictionist and see what sort of consensus we can arrive at. By the way, had the person you consulted with ever heard of tianeptine?
Not until I mentioned it, but he’s familiar with drugs of that ilk. And he’s truly an adept neuropsychiatrist.
He does have a few acquaintances in the field that he thinks would be knowledgeable in the area of tianeptine, I’ve now asked him if any are in SoCal. I’ll let you know if they are.
There’s a great addiction medicine program based at UCLA medical center, my friend tells me.
I’ve heard of it. Unfortunately, I moved to the Portland area several months ago.
Well, that’s what happens when you don’t update your profile.
OR or ME?
I have a medical condition (Restless Legs Syndrome) for which gabapentin is one of the primary treatment regimens. I had NOT heard that it was susceptible to abuse. I’ll have to ask the sleep specialists next time I see them (I’m not personally on gabapentin, I’m using a dopamine agonist).