2009 - August

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.

About the Author

Mike Leath, MD is Board Certified in Family Medicine and is certified by the American Board of Addiction Medicine (ABAM). He is Medical Director of Outpatient Programs for Memorial Hermann Prevention and Recovery Center (PaRC) in Houston. www.mhparc.org

( 7 Votes )
Comments (7)
7 Saturday, 15 October 2011 18:30
Soraya K.
I do not agree with "touch" dosing in an inpatient detox setting. It does nothing but prolong opiate withdrawal. I understand the clinician's concern for addiction to Bupenorphine, but most outpatient doctors agree that patients can be subletly weaned off this drug as opposed to having it once or twice and then getting cut off. Bupenorphine is a class III drug and has a withdrawal just like any other opiate. I can imagine that it is rather difficult to get "excited" about the 12 step process, going to meetings, finding a sponsor, etc., etc., when one is in acute withdrawal. Just my 2 cents....thanks.
6 Saturday, 29 August 2009 13:32
Danielle Brown
What an awesome article. Very detailed and helpful for individuals considering Buprenorphine treatment as well as individuals who administer the medication.
5 Saturday, 15 August 2009 10:14
Michelle Wright
I think these outpatient clinics are sometimes as guilty as the pusher. I was addicted to the blues (roxicets). I used about 90 mg a day, 3 pills. Definately was not the heaviest addict they have treated, yet they wanted to put me on 12-16 week supply of Suboxone. Why? Because every week they wanted me to come in and charge me for the visit and then give me a 7 day use of the Subs and then do it all over again. THATS where they make their money, so it isn't always cheap.
I used the Bupe for one week and was clean and have been now for 9 months. They have called me and were adament about me coming back. I was like "i'm clean" thank though ha ha
4 Monday, 10 August 2009 22:28
Tim Mathes
I was given Subutex for 6 days during an in-hospital detox. I was told that I could get out quicker if I stopped taking the Subutex. I stopped taking it after the 6 days and was released on the 7th. This was following a 3 year addiction to MScontin, methadone and hydrocodone. I went immediately into the 12 step recovery program and currently have been drug free for 20 months. I am thankful that Subutex did not become just a further addiction. The 6 days was enough to get me through the roughest part of detox. Maybe a hospital setting is the best for the use of this drug.
3 Saturday, 08 August 2009 04:12
susan Lief
How about some CEU's for reading articles
2 Tuesday, 04 August 2009 12:23
Tosh W.
Every person is different. Sub worked for me after a 3 year battle with Roxicodones. I agree that there is a psychological side that is not fully addressed in an outpatient care, but if a person is showing up to truly detox like I did, they will work through it. I admit that when I got detoxed there was sort of a phase where I missed "the act" of and "the looking forward to" of the drug, and maybe some or most would have relapsed with that thought in mind. I was lucky.
I agree with the doctor but I do think outpatient clinics with some counseling is an affordable and successful way to go if you want it.
1 Tuesday, 04 August 2009 09:29
Tom Berney
Great infomation,After years trying to detox on suboxone on out patient I gave up.the half life of suboxone is to great and the detox to painfull that I found i could not get off it no matter how hard I worked at it.

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