by Robert M. “Mike” Leath, MD

Buprenorphine, a synthetic opioid marketed as Suboxone or Subutex, has given physicians an effective new treatment tool in helping opiate dependent persons. It is a helpful agent used by treatment providers whose philosophy is either harm reduction or abstinence. When the goal is to move the patient away from dependence on addictive opiate medications or drugs, an option is to use Suboxone as a temporary agent to safely and comfortably move someone through the withdrawal phase.

The move towards outpatient detoxification is understandable: it is less disruptive to the patient’s schedule, less costly, and more convenient. Patients who are appropriate for outpatient detox can seek assistance from a physician trained in this procedure in an office environment and continue their professional or other activities simultaneously. On the other hand, opiates are often not the only addictive drug being used--many patients who receive buprenorphine on an outpatient basis are poly-substance dependent. These patients are generally less compliant with treatment directives and follow-up. The process for weaning a patient completely off of buprenorphine in an outpatient setting is also drawn out considerably, sometimes up to 18 months .

In an inpatient setting, buprenorphine may be used more conservatively via a “touch dosing” method in combination with other medications for opiate withdrawal. It can make the patient more comfortable by easing withdrawal symptoms, reducing craving and blocking the effects of opioids during the detox process. Within a week or so of entering treatment, the patient is no longer being administered an addictive medication. Again, if the objective is abstinence, then this is the preferred approach. Buprenorphine does not have to be used as a substitute of one addictive drug for another in the same class.

In my experience, and that of many of my addiction medicine colleagues, outpatient detox using buprenorphine for opiate addicts is not as successful as desired. Patients are typically enthusiastic with the initial plan to taper and then discontinue the Suboxone, but after the plan is put into action, the enthusiasm often wanes. Not infrequently, the patient will feel our taper is too rapid. The most resistance is met when we try to discontinue the final dose. Fortunately, this is not always true. When a patient is involved in a recovery program, he or she is more focused on the recovery process and less so on the medication, so our mutual goal is quickly and easily met. The real benefit that this patient will realize is the contentment of life without a drug being the focus.

Many patients feel that if they can just detox from narcotics with the help of buprenorphine, then their worries will be over. Sadly, this is rarely the case. A psychological dependence is also created and patients are fiercely resistant to giving up that last dose of medication in order to move into a fully drug-free state. In some cases, the patient discontinues coming to see their attending physician altogether, seeking out another physician, who will continue to prescribe the medication rather than giving up that final dose.

Buprenorphine has become the preferred substitute for Methadone maintenance as it is safer and more convenient. In its two marketed forms Suboxone and Subutex are taken sublingually. They have less effect if swallowed. In an attempt to thwart abuse, buprenorphine is combined in the same tablet with a narcotic antagonist, naloxone, which can block the effect of any opiate, including buprenorphine. Naloxone, however, is not absorbed when placed under the tongue or swallowed, so when used as directed it will in no way interfere with the buprenorphine in the Suboxone. However, if the patient attempts to dissolve the Suboxone and inject it, then the naloxone in the preparation will not only block the desired effect of the buprenorphine, but will override and block the effect of any opiate in the individual’s system thereby precipitating acute opiate withdrawal.

The detox process alone is not designed to deal with the psychological, social, and behavioral problems associated with addiction, so it does not produce the lasting behavioral change necessary for recovery. As a result, an “outpatient detox only” approach has a higher risk for relapse. The disease of addiction is multifaceted and it impacts the behavioral as well as the physical. Compliance with a treatment plan involving counseling and intensive outpatient treatment is critical, yet many people want the medication without engaging in the equally important work of recovery.

While every case deserves an individualized evaluation and treatment plan, there are many common characteristics among addicts and other dependent persons, such as a lack of self esteem, the need to use drugs to suppress hurtful feelings, the use of drugs to self-medicate, developing drug tolerance, and so on; and it is because of these things that a physiological detox may not meet all the patients needs, but is a great start. Please, ask your physician if you feel you may be a candidate for such a treatment. If your physician does not feel comfortable carrying out such an evaluation and treatment plan, he or she can refer you to an addiction specialist.