Suboxone, the “Miracle” Drug

The patient quoted in the Suboxone success story, printed in this blog over the last few days, obviously has a healthy recovery on buprenorphine, and plans to continue his present recovery program. He goes regularly to Narcotics Anonymous meetings, has a sponsor, works the twelve steps of recovery, and contributes to NA by sponsoring people and doing other service work. He had such a good outcome, because he didn’t neglect the psychological aspect of his recovery, even after Suboxone took away the physical withdrawal symptoms.

For the patients I treat with buprenorphine, the most challenging part is coaxing, coercing, and cajoling patients to get some sort of counseling. Whether they go to an individual counselor, pastoral counselor, or to 12-step meetings doesn’t matter to me. I’d love to be able to send them to local intensive outpatient treatment centers, but as will be discussed later, most of these centers require the patient be off buprenorphine completely, before they can enter treatment, which can create a curious circle of relapse. Fortunately, I know good counselors, knowledgeable about addiction and its treatments, willing to see my buprenorphine patients. They markedly benefit from this individual counseling, though group settings can give patients insights they won’t get any other way.

When buprenorphine was first released, the addiction treatment community and opioid addicts had very high hopes for this medication. Many patients say, “It’s a miracle,” on their second visit, after they‘ve started the medication. Most patients are surprised they don’t feel high, and don’t have any withdrawal symptoms.

However, it’s really not a miracle drug. It’s still an opioid, and though it’s weaker than other opioids, some patients have extreme difficulty when they try to taper off of this medication. One can read postings on internet message boards that describe the difficulty some patients have.

In my own practice, I’ve had some patients who stopped buprenorphine suddenly, and claim they had no opioid withdrawal symptoms. At the other extreme, I’ve had patients who wean to Suboxone one milligram per day and say they get a terrible withdrawal, if they go a day without even this one milligram. I’ve had many patients who gradually cut their dose on their own, until they take the medication every other day, and gradually stop it.

Patients appear to differ widely in their abilities to taper off buprenorphine. Some patients are dismayed to discover it’s just as hard to taper off of Suboxone, and stay off opioids, as it is to taper off methadone and stay off opioids.

If it’s appropriate to consider tapering a patient off of buprenorphine, best results are seen if the taper is done slowly. In the past, I have informed patients who wished to taper completely off buprenorphine that addiction counseling improves outcomes, and reduces relapse rates, but this may not be true.

Information presented at the American Psychiatric Association’s 2010 conference calls that advice into question. In a study of over six hundred prescription opioid addicts, relapse rates were remarkably high when patients were tapered over the course of one month, after two months of stabilization. (2) The addition of fairly intensive addiction counseling didn’t improve relapse rates. In the treatment as usual group, prescription opioid addicts met weekly with their doctors, and after their taper, ninety-three percent had relapsed within four weeks. Even in the group getting doctor visits plus twice- weekly one hour counseling sessions, ninety-four percent relapsed within the first four weeks after buprenorphine was tapered. This was the largest study done so far, specifically on prescription opioid addicts, as opposed to heroin addicts. The overall message from initial results of this study seems to be that adding fairly intense drug counseling doesn’t improve patient outcomes, if the buprenorphine is tapered off within the first three to four months.

Once a patient is on buprenorphine and doing well, he or she often becomes very reluctant to participate in counseling, or even 12-step meetings. Once patients feel physically back to normal, they begin to minimize the severity of their addiction, and don’t think they need any counseling.

Some patients admit they need counseling, but say they can’t afford it. This is a valid excuse, because counseling sessions can cost around a hundred dollars each. Private counselors usually like to see their patients weekly, so that’s an additional four hundred dollars per month that patients need to pay. Even patients with insurance are allowed only a limited number of sessions. Those without insurance have great difficulty affording counselor fees on top of all the other expenses, like doctors’ visits, drug screens, and medication. Patients have fewer valid excuses for not participating in Narcotics Anonymous or Alcoholics Anonymous, since they’re free, and located in nearly every city or town. I have more patients who will go to these meetings.

1. Amass L, Bickel WK, “A preliminary investigation of outcome following gradual or rapid buprenorphine detoxification” Journal of Addictive Disease, 1994; 13:33-45.
2. Weiss RD, The American Psychiatric Association 2010 Annual Meeting: Symposium 36, presentation 4. Information from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study, May 23, 2010, New Orleans, LA.

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4 responses to this post.

  1. Treatments for Opioid Withdrawal…

    I found your article interesting thus I’ve added a Trackback to it on my weblog :)…

    Reply

  2. Posted by Chris Pape on January 13, 2011 at 11:11 pm

    I am a an opioid dependent person currently taking suboxone. I’ve been on it for 2 yrs and have no scheduled date to discontinue. I’ve tried abstinece for 2 whole yrs, and although I did not relapse on opioids, I was totally disabled, used other drugs, could not work, gained 50lbs, etc. My main comment is that although NA is free, they DO NOT approve of suboxone. Each group has the authority to not allow someone on suboxone to share at all. This is rarely enforced, but a recent bulletin of NA’s board members determined having any mbr on suboxone or methadone to lead a mtg, be a speaker or talk on the behalf on NA would be too damaging to NA to be allowed. We need to change these attitudes, as the vast majority of sponsors put enormous pressure on a sponsee who’s on suboxone to discontinue against dr’s advice because they are not clean. No one seems to want to call out the 12 step groups on this damaging attitude.

    Reply

  3. Posted by James Johnson on January 20, 2011 at 4:02 pm

    Buprenorphine is not weaker than other opiates; it just produces less euphoria than full agonists. On the contrary, Buprenorphine is actually EXTREMELY potent, hence being able to successfully prevent withdrawal from heroin, oxycodone, and the like.

    To suggest that buprenorphine is weaker than other opiates is dangerous. Were some opiate naive individual to read your post and confidently take a full 8mg dose, assuming it’s weaker, they could very well die. Even the tiniest sliver of an 8mg tablet is enough to make an opiate naive person very ill. When buprenorphine is used for pain management the doses administered are usually around 0.5 mg, if that gives you an idea of the potency.

    Please be careful making these kinds of statements publicly on the internet. Being that you are someone authorized to prescribe this medication, unknowing readers would likely accept your statements as truth. Just make sure that what you’re saying is true, especially with something as potent as buprenorphine.

    Reply

    • Sorry, but I don’t think I ever said any opioid is safe to take, unless prescribed by a doctor, who knows your medical history. As I’ve written repeatedly in this blog, it’s never, never, never safe to take any prescription medication that’s not prescribed to you.

      As to buprenorphine and its potency – it’s a partial opioid. It is does not give as strong an opioid effect as methadone, a full opioid. This makes buprenorphine a safer (note I’m not saying completely safe) drug.

      Potency is the measure of the amount of drug required to produce a given effect. For example, clonidine, a blood pressure pill, is dosed in .1mg pills. Methyldopa, another old-time blood pressure pill, is dosed in 125mg pills. This means clonidine is more potent, milligram per milligram. But doesn that mean that clonidine is more effective than methlydopa? No. Clonidine, dosed at .1mg is about as effective as methlydopa, dosed at 125mg. You are confusing efficacy with potency, and they are not the same.

      Methadone has much more opioid effect than buprenorphine.

      You are also confusing the intravenous dose with the sublingual dose of buprenorphine. In the 1980’s, we used Buprenex, an injectable liquid, in doses of .3mg. Sublingually, it’s much less bioavalable, which means less gets into the bloodstream, requiring larger doses to achieve the desired effect.

      Reply

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