Some Difficulties of Using Buprenorphine at the Opioid Treatment Program

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As I’ve described in recent blog entries, buprenorphine, better known as the brand names Suboxone and Subutex, is now being offered at some opioid treatment programs as an alternative to methadone for the treatment of opioid addiction.

Buprenorphine is much safer than methadone, and works well for many patients. Since it’s a partial opioid instead of a full opioid, most patients find it’s easier to taper off of than methadone. However, some patients have a difficult time tapering off of it, too. It’s not a perfect medication, but is another tool we can use.

When medication is prescribed at an opioid treatment program (OTP), federal and state regulations decree the OTP must observe each patient take his or her dose of medication daily, until the patient meets criteria for take home doses. With methadone, the patient quickly swallows the dose, speaks to the nurse to prove it’s been swallowed, and is done with the dosing process.

But with buprenorphine, particularly with the generic, each patient needs ten or fifteen minutes to dissolve their dose. This means a longer process for the patient, and a longer time of observation by staff, to make sure no diversion occurs. The staff of the OTP need to make sure all of the buprenorphine has been dissolved and no dose remains before the patient leaves. In both of the programs where I work, buprenorphine patients sit in an area reserved for them while medication dissolves. This area has to be closely monitored by a counselor or nurse. Thus, buprenorphine dosing is a little more labor-intensive, and takes some extra space in the clinic that’s not needed for a methadone-only clinic.

I’ve been surprised and disappointed at how many patients try to divert part of their dose. Some try to slip it from their mouth to a pocket or tissue, so we’ve had to ask all patients not to touch their face with hands or tissue while dissolving. Several patients tried to slide a partially dissolved dose into their bra. When we see a patient clearly attempt to divert medication, we crush the tablets and the patient places this powder under the tongue to dissolve, rather than dispense whole tablets. We can be sure there will be no diversion doing this, but I can’t find any data that says the absorption and blood levels will be unaffected. Still, it seems a better option than switching to methadone or asking the patient to leave treatment.

Diverted doses are often intended for sale on the black market. If a patient has sold or attempted to sell a dose, that patient can’t get any take home medications at all, and can’t dose at all unless we can be sure they are taking all of their dose without diversion.

However, some patients who are caught trying to put part of their dose in a pocket say they want to save part of their medication for self-use later in the day. This does make sense, in a way. While using illicit drugs, most addicts use short-acting opioids that require administration of the drug three or more times during the day to ward off withdrawal. Addicts become accustomed to taking a drug when they feel any physical or emotional discomfort. That tendency doesn’t go away quickly in some patients, even when they are on medication like buprenorphine that only needs to be taken once daily to prevent withdrawal. That compulsion to take something remains for a period of time as part of the addiction, and has to be addressed with counseling. For some addicts just starting treatment, it’s scary to think they will have nothing to take later in the day.

Once I treated an addict who was addicted to pills containing barbiturate, acetaminophen, and caffeine. She took fifteen or twenty pills per day. She went into a medical detox, then an intensive outpatient program, and remained abstinent from all drugs. However, she compulsively took acetaminophen, particularly during times of stress. She chewed them, despite their bitter taste, because that’s how she used her drug of choice. She said the bitter taste of acetaminophen somehow calmed her when she felt bad. This behavior persisted for the better part of a year, and she had difficulty trying to stay under the maximum recommended dose of acetaminophen, despite knowing it could cause liver damage.

Clearly, she wasn’t getting a high from acetaminophen. But she was used to taking something multiple times during the day, to make her feel better. Also, since the drug of abuse, a barbiturate, had been paired with acetaminophen’s taste for so long, I think it’s possible her brain still released the same sort a pleasure chemicals as it did when she used the addicting drug.

We can’t allow patients to take part of their dose at home during the start of treatment, though I’m sure many of my office-based patients take their medication in divided doses. Buprenorphine works better for pain in divided doses, but if the patient only has addiction, and no pain, I prefer the dose be taken all at one time. That means my patient only has to think about taking medication once per day.

If Suboxone film could be affordable enough to use for dosing at opioid treatment programs, it would solve most of these issues. The film dissolves quickly, so once it’s placed into the mouth, it would be difficult to spit out for later use or for sale. Patients wouldn’t have to wait long for their dose to dissolve.

If they were smart, the Reckitt-Benckiser pharmaceutical company, manufacturer of Suboxone and Subutex films, would offer special much-reduced pricing to opioid treatment centers, perhaps matching the generic or even lower than the generic. The company could regain a market share lost to the generic monoproduct, and garner some good will in the process. As an added advantage, their concern about pediatric overdoses could be further allayed. Daily dosing of patients new to recovery at opioid treatment programs would keep the film out of the homes of small children, further reducing pediatric risk. Perhaps only after the patients make progress in their recovery would they be allowed to take the film home as take out doses.

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2 responses to this post.

  1. Posted by Michael Flanagan on March 22, 2013 at 4:45 pm

    I am looking for some information on the dissolving time for the Suboxone Film. Is it possible for the film to dissolve under 60 seconds

    Reply

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