More Information about Buprenorphine

Buprenorphine, commonly known by the brand name Suboxone, is an exciting new option for opioid addicts seeking help, and for the doctors who treat them. For the first time in nearly one hundred years, people with the disease of opioid addiction can be treated in the privacy of a doctor’s office. Addicts no longer have to go to special clinics to get medication for their disease. Since many opioid addicts don’t live near a methadone clinic, or live near a methadone clinic that has a six month wait for admission, or wouldn’t be caught dead in a methadone clinic due to the stigma, buprenorphine is a fresh option.

Congress passed the Drug Addiction Treatment Act of 2000 in order to allow the treatment of opioid addiction in office-based practices, instead of the more cumbersome methadone clinics. In 2002, the FDA approved buprenorphine as the first schedule III controlled drug that could be used under the DATA 2000 Act. The drug became available in pharmacies in 2003. Thus far, buprenorphine is the only medication that’s approved by the FDA to treat opioid addiction in a doctor’s private office.

 The Supreme Court’s interpretation of the Harrison Drug Act of 1914 made it illegal for physicians to prescribe opioids from an office setting for the treatment of opioid addiction, and it remained illegal until DATA 2000 was passed. DATA 2000 was therefore quite remarkable for the change of attitude it showed on the part of government policy makers. It showed an open mindedness rare in the history of addiction treatment in the U. S.  For the first time in more than eighty years, the government was not only granting permission for appropriately trained and licensed office-based doctors to prescribe controlled substances to treat opioid addiction, but they were actually encouraging it. However, buprenorphine still has special restrictions on its use.     

  In order to prescribe buprenorphine to treat addiction, a physician must have a special DEA number, called an “X” number. To get that number, the physician must attend an eight hour training course to learn about opioid addiction and its treatment with buprenorphine. After a doctor is qualified by training, she can then apply to the Substance Abuse and Mental Health Services Administration (SAMHSA) for a waiver from the regulations of the Controlled Substances Act. If granted, this means the physician doesn’t have to meet all of the conditions and regulations of traditional opioid addiction treatment centers (methadone clinics).

 The doctor must certify she has the capacity to refer patients for counseling in addition to prescribing buprenorphine, and cannot treat any more than thirty patients at any one time. After SAMHSA grants the waiver, the DEA gives the doctor a special DEA number, to be used only for patients who are being treated for addiction. After one year, the doctor may apply for permission to treat up to one hundred patients at any given time.

 By September of 2009, nearly 24,000 physicians were trained to prescribe buprenorphine, but only around 19,000 of these doctors applied and received their DEA number to prescribe buprenorphine. Only 3,685 doctors applied for permission to treat up to one hundred patients. By 2009, around 500,000 patients were receiving buprenorphine prescriptions. (1) About twenty-seven percent have been on tapering detoxification schedules and the rest, seventy-three percent, have been on a maintenance schedule. (2)

Recently, there has been a trend toward using buprenorphine as a maintenance medication, rather than for a relatively quick detoxification, as studies are showing greater benefit with longer use. One large study being performed specifically on prescription opioid addicts showed very high relapse rates (96%) if buprenoephine is tapered after only four months of fairly intense counseling. (3) As this study procedes, we’ll get more information about what duration of treatment is ideal with buprenorphine.

  Just as with methadone, the medication alone rarely is enough to get the patient into successful long term recovery. Buprenorphine is not meant to be a stand-alone treatment, but must be combined with some sort of counseling. According to the government regulations, the prescribing physician must have the capability to refer the patient for counseling, though it doesn’t specify the type or intensity of the counseling.

 Buprenorphine is an opioid. If it’s stopped suddenly, a typical opioid withdrawal will begin within several days. Addicts (and their doctors and families) want a pill that cures opioid addiction, but has no withdrawal symptoms if stopped, but that’s not how this medication works.

 Buprenorphine treats the physical symptoms for as long as the drug is taken, and reduces mental obsession for opioids. Most patients say buprenorphine withdrawal is somewhat milder than withdrawal from other opioids, but a small number say it’s worse. A few patients have said they felt no withdrawal after stopping it. If a patient wishes to be taken off buprenorphine, the dose should be reduced gradually, as some patients tolerate a faster taper than others. Patients appear to vary widely in their ability to tolerate buprenorphine taper.

 Buprenorphine works because of its unique pharmacology. Buprenorphine, like methadone, is a long-acting opioid. This means both drugs prevent withdrawal for at least twenty-four hours, which makes them ideal to use as opioid replacement medications.

 Buprenorphine is a partial opioid agonist. This means that while it activates the opioid receptors in the body, it does so less vigorously than full agonists like morphine, methadone, or oxycodone. People usually experience it as an opioid, but in those already addicted to opioids, it doesn’t cause a high or euphoria. If someone has never taken opioids, buprenorphine will cause a high, but tolerance develops quickly to that effect.

 Buprenorphine has great affinity for the opioid receptors, which means it sticks to them like glue. If any other opioids are in the body, buprenorphine will kick them off the opioid receptors. Because it’s a weaker opioid, this can put the patient into relative withdrawal. Therefore, to start buprenorphine successfully, it’s important for the patient to be in at least moderate opioid withdrawal. This is very important, for if an opioid addict takes buprenorphine while he is taking another opioid, he will suddenly feel terrible, and have what is called precipitated withdrawal, the sudden onset of opioid withdrawal symptoms. Most addicts want to avoid that awful feeling at all costs. Some physicians, not knowing about the need to be in withdrawal before starting this medication, have put their patients into precipitated withdrawal by starting Suboxone too early.

To Be Continued

  1. Clark, H. Westley, M.D., J.D., MPH, CAS, FASAM, Director of Center for Substance Abuse Treatment and Mental Health Services Administration, Keynote address, component Session 6,  American Society of Addiction Medicine’s Course on the State of the Art in Addiction Medicine, Washington, D.C., October 24, 2009
  2. John Renner, MD, “Educational Status Report” lecture at American Society of Addiction Medicine, component session IV 905, New Orleans, LA, May 1, 2009.
  3. Weiss, R, information from National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study, presented at the American Paychiatric Association Annual Meeting,  May 2010 New Orleans, LA
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6 responses to this post.

  1. More Information about Buprenorphine « Janaburson's Blog…

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

    Reply

  2. “Recently, there has been a trend toward using buprenorphine as a maintenance medication, rather than for a relatively quick detoxification, as studies are showing greater benefit with longer use. One large study being performed specifically on prescription opioid addicts showed very high relapse rates (96%) if buprenoephine is tapered after only four months of fairly intense counseling.”

    The trend toward using buprenorphine as a maintenance drug seems very pernicious to me. From all the anecdotal evidence I’ve read (and I’ve read tons of it), buprenorphine works well as a very short-term detox tool, used for < 3 weeks. If used for longer than that… well, as you say, it sticks to the receptors like glue, and it will in general create a very strong post-acute syndrome that will drive the addict to use again after the taper is over.

    I myself used buprenorphine to get off fentanyl; I took suboxone for 8 weeks and wish I had cut that time in half. I could have, but I was afraid of Not Taking Something.

    I also find it very disturbing that buprenorphine–an opioid, plain and simple–is being marketed and accepted as a "medication" that "reduces the mental obsession for opioids." One opioid will indeed "reduce the obsession" for another opioid. That's pharmacology. It doesn't matter whether it's a partial-agonist or not. It is an opioid drug, and a very, very strong one–many physicians do not have respect for its sheer strength.

    Extremely important talk with Steven R. Scanlan M.D., a Florida detox physician who works with patients using Suboxone:

    http://afflictedandaffected.com/index.php?option=com_content&view=article&id=248:steven-scanlan&catid=40:shows2008

    Scanlan's experience is that it's harder to get patients off long-term buprenorphine therapy than it is to get them off methadone. … Please, use it short-term only.

    with every good wish, –G

    Reply

    • I am glad you wrote. You’re right, it is an opioid, and stopping any opioid is difficult. But you’re missing the point of replacement medications. They aren’t meant to be stopped after short-term use. If I have a patient who says they want to be off opioids within the next few months, the method with the highest success rate is to go to an inpatient detoxification unit for withdrawal management, followed by an inpatient residential treatment program of no less than 30 days. Less than that, and relapse rates are very high.

      I sense that you are saying that the only worthwhile recovery is completely opioid-free recovery. I think that’s a nice ideal, but it doesn’t work for everyone.

      First of all, not everyone can afford that gold standard of treatment, and not everyone who undergoes that gold standard is successful. Some people still feel pronounced opioid withdrawal symptoms for many months. If that person is able to stay off all opioids, great. If not, thank God there are two replacement medications that can help the person feel normal again, and function normally.

      This is a fatal disease. For opioid addicts, there’s a very high mortality rate unless they get into recovery. Opioid replacement medications reduce that mortality by anywhere from eight times to sixty-three times. The following examples are studies of methadone, but I suspect we’ll see the same kind of results for buprenorphine, too.

      (Goldstein A, Herrera J, Heroin addicts and methadone treatment in Albuquerque: a year follow-up. Drug and Alcohol Dependence 1995 Dec; 40 (2): p. 139-150. A group of heroin addicts were followed over twenty years. One-third died within that time, and of the survivors, 48% were on a methadone maintenance program. The author concluded that heroin addiction is a chronic disease with a high fatality rate, and methadone maintenance offered a significant benefit.)

      (Gronbladh L, Ohlund LS, Gunne LM, Mortality in heroin addiction: Impact of methadone treatment, Acta Psychiatrica Scandinavica Volume 82 (3) p. 223-227. Treatment of heroin addicts with methadone maintenance resulted in a significant drop in mortality, compared to untreated heroin addicts. Untreated addicts had a death rate 63 times expected for their age and gender; heroin addicts maintained on methadone had a death rate of 8 times expected, and most of that mortality was from diseases acquired prior to treatment with methadone.)

      Reply

  3. Anxiety, step-work, and gratitude…

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  4. Brittany Murphy’s medications and their interactions…

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  5. Posted by Eric on September 20, 2010 at 2:45 am

    Hello…
    Ive been on suboxone for a about a year now and was wondering what this new strips of suboxone look like and how long until they reach pharacies in pennsylvania… is it a year or so away or should we be expection to have this new type of medication at the pharmacy soon… im just cuious as to hold long it will talk to get to my pharmacy in lock haven pennsylvania…. thank you……

    Reply

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