To Taper or Not To Taper…

aaaaaaaaaaajudgy cat

 

Below is a comment responding to my last blog post, and my answer to it. I thought this aspect of buprenorphine treatment was so important that it’s worth a blog of its own.

While I wholeheartedly disagree with a decision not to stock any buprenorphine products at a pharmacy, I understand what led to it. The area has a troubling pattern of buprenorphine use to maintain dependence instead of being tapered to actually treat the dependence and help the patient. A pharmacist should be able to refuse prescriptions that are being prescribed and/or used inappropriately without having to fall back on a blanket “we no longer stock it” statement. Ensuring that patients who are being gradually tapered to treat dependence or bring treated for pain have a harder time getting their medication is not an acceptable way to lessen the abuse.

         Posted by janaburson on July 28, 2016 at 8:56 pm  edit

Aha!! You may be on to something. Maybe these pharmacists think, like you do, that buprenorphine should be tapered, instead of being used as a maintenance medication. When it first came out, I think many of us hoped we could taper people off of it quickly. However, more & more studies are showing that the patients who stay on buprenorphine do the best. By best, I mean not dying, no illicit opioid use, can hold down a job, finish school, be a good parent, etc.
People who taper have a high relapse rate. Relapses can be deadly. Our opioid overdose death rate is already too too high. Let’s not make it worse by insisting opioid use disorder be treated like a short-term illness, rather than the chronic disease that it is.
Having said that, patients are different, and taper may be appropriate in selected patients. But it’s not a quick process and it takes time to get the counseling and make life changes.
Would you tell a diabetic, who is not eating right or exercising, that they should taper off metformin, since if they changed their behavior, they would not need medication?

I forget there are still people who think buprenorphine should only be used temporarily, as a detoxification medication. I’m not saying that’s always wrong. A minority of patients may do well with only a taper, but most patients with opioid use disorder do better if they stay on buprenorphine long-term.

Does that mean these patients should never taper off buprenorphine? I’m not willing to say that either. We don’t have enough information from good studies to show us how long is long enough.

We do have studies now that tell us tapering off buprenorphine after a few months of stabilization isn’t going to produce best outcomes for most patients.[1, 2, 3]

We also know active opioid use disorder is associated with a high mortality risk.

Some people do misuse buprenorphine, and shouldn’t be kept on this treatment. Those patients will do better with another form of treatment, perhaps methadone.

Let’s take what we know about opioid use disorder and its treatment with buprenorphine, and apply it to an imaginary disease that has no moral judgment attached. Let’s call our disease “Syndrome X.”

We know Syndrome X causes a great deal of emotional, physical, and spiritual suffering. It can occur in anyone, and has a high mortality rate. It can be effectively treated with a medication that is relatively safe, and does not cause euphoria when used correctly. However, the medication can cause some withdrawal if it’s stopped suddenly.

While on medication, patients with Syndrome X feel normal, unlike how they feel off medication. On medication, these patients are more likely to be in better physical health, mental health, and are more likely to be employed. They are more likely to be productive members of their families and their communities.

The studies of patients with Syndrome X show pronounced reduction of death rates while patients are on medication, as well as lower rates of infectious diseases. We also know from studies that if patients with Syndrome X are tapered off their medication, their death rates increase anywhere from three times to sixteen times compared to if they stayed on their medication.

Who in their right mind would ever recommend tapering the medication? Who would say to their loved one, “You’ve got to get off of that stuff. You just need to be strong.” Or, “Isn’t it time you stop using that crutch?”

It’s only because of the stigma this country has against people with substance use disorders that tapering off a life-saving medication is even an issue. If we were talking about any other chronic illness, there would be a loud clamor for every person to be able to get on and stay on that medication. In fact, doctors not prescribing a medication with as much benefit as buprenorphine has for opioid use disorder would be accused of malpractice.

I don’t push my patients to taper off buprenorphine. If that is their desire, I’ll do everything I can do to help them. I tell them what I’ve seen work in my other patients, work with them on relapse prevention, and encourage them to go slowly, to give their brain time to adjust as their dose comes down.

I’ve had many patients taper successfully, and most of them did this after at least a few years of stability on buprenorphine. When I see new patients, I tell them this isn’t (usually) a quick fix that they can do in a few months and be cured forever. A few lucky patients are able to taper quickly but I think we now have studies showing this isn’t the situation for most people with opioid use disorder.

How about this: leave the timing of the taper up to the patient and their doctor.

If you aren’t one of these two people, maybe you don’t get to have an opinion on when or even if a taper should be attempted.

1.Fiellin et al, See comment in PubMed Commons belowJAMA Intern Med. 2014 Dec;174(12):1947-54.

This study concluded “Tapering is less efficacious than ongoing maintenance treatment in patients with prescription opioid dependence who receive buprenorphine therapy in primary care.” The taper arm of the study was started after six weeks of stabilization, with a three week taper. Patients on the taper were offered medication to help withdrawal symptoms and also offered naltrexone treatment. Patients who tapered were significantly more likely to have opioid-positive drug screens compared to the patients who remained on buprenorphine maintanence. Patients on maintenance were significantly more likely to remain in treatment for addiction counseling that the patients were tapered.

2.Marsch et al,  See comment in PubMed Commons belowAddiction. 2016 Aug;111(8):1406-15.

This study of fifty-three young people aged 16 to 23 were enrolled in a double-blind, placebo-conrolled trial. Subjects enrolled in the arm of the study where buprenorphine was tapered over fifty-six days were signigicantly more likely to have opioid-negative drug screens and continued participation in treatment compared to subjects given twenty-eight day tapers

3.Weiss et al, Prescription Opioid Addiction Trial

“Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial.”  Archives of General Psychiatry 2011.

This study of prescription pain pill users found that taper off buprenorphine after stabilization shows a high relapse rate.

Advertisements

7 responses to this post.

  1. Posted by Alan Wartenberg MD on August 1, 2016 at 2:25 am

    As I have said endlessly, if we lived in the best of all possible worlds, early life repetitive trauma, which I believe an enormous amount of evidence indicates is the primary insult that leads to addiction (when combined with inadequate resiliency, at least), would never happen, and addiction would become exceedingly rare. If we were in something even close to the best of all possible worlds, this early life trauma and its consequences would be recognized early, with a focus on trauma-centered care, perhaps even use of beta blockers very early on, and perhaps addiction would be at least less common. And if we lived in a much better world, if not a perfect one, long-term psychotherapy, with a trauma-centered focus would be available later in life, when addiction has already occurred, so that people who need to self-soothe with opioids could ultimately successfully taper off.

    But what we have is a highly imperfect world, where that care is NOT available to many, is inaccessible, too expensive, and there are too few people trained to do it. We have a world where people want traumatized individuals to “suck it up and fly right” just because they say so, or because they were able to do it.

    It is bad enough to have a world where people cannot get the help they need. It is even worse to have one with self-righteous moralists who do not understand the unending pain that some of us experience, where we no longer can make the endorphins that can soothe our pain and distress, but those moralists want to remove the medication which allows us to live within our own skin.

    Reply

    • Posted by Belle on August 1, 2016 at 3:45 am

      Our son overdosed twice – needing Narcan both times- because a PA decided he should go off of his Vivitrol shot. Thankfully, he survived and is now in a 24-hour rehab and will get his next shot in as soon as it is medically possible. He was not offerred oral buprenorphine so he could even try to taper. He just was told to stop.

      He is a 26 year old man who had, 15 months clean, a decent job and was very active in his recovery community. Now we are not sure what his future holds. Sometimes, the judgment and bias start with the medical personnel. And what is the patient to do in that situation? He should have spoken up, but the “power over” nature of our medical system does not encourage that. So he nearly lost his life.

      He can recover from relapse but our faith in the treatment systems here is deeply shaken. At least he is alive.

      Reply

  2. Posted by Jennifer Palmer on August 2, 2016 at 12:15 am

    I have been on suboxene for a year and 3 months and I’m bring forced to taper unless I can pay cash which I can’t do so I’m scared to death and I’m do afraid I know I’m not ready but not much I can do my husband died from a heroin overdose I just hope I’m strong enough and can get through this but I’m on disabity for depression and this tapering is making it worse…

    Reply

  3. Posted by Robin on August 3, 2016 at 11:30 am

    And I think Dr Burson hit the nail on the head as she so often does.

    We live in a world where far too often the opinions of what we’ll call “civilians” creates policy.

    Instead of an MD (or a team that includes at least one MD) creating policy (which translates into practice ) for a medical disorder (in this case, substance abuse), we have pharmacists, judges, corrections staff, counselors, Congresspeople, attorneys, rank-and-file staff at many different types of institutions a person afflicted with said disorder is likely to find themselves, and the general public all getting a say in how “treatment” is provided, what constitutes acceptable treatment, and what is not allowed as such (often Buprenorphine or
    Methadone treatment, or amounts that are permissible to prescribe or dispense).

    When I went through the wringer in drug court (2008), no MAT except Vivitrol was accepted. Vivitrol was given in the jail, by a nurse, to uninformed patients who would accept it only as a “get out of jail” card, out of desperation.

    All of these above mentioned people have a huge bearing on what kind of treatment a loved one of yours (or you) can receive. And this should be considered unacceptable; it WOULD be were it anything else standing in as the disease/disorder.

    And whenever I hear of things like that happening, I feel as though all of those people are trying to practice medicine illegally. It isn’t somethi that happens in a void, either; it directly impacts and causes deaths and suffering, usually needless.

    Thanks for your blog, Dr Burson.

    Reply

  4. Dr. Wattenburg,

    Please excuse my ignorance but excepting a treatment option for medication induced prolonged QT syndrome what benefit does a beta blocker give to a person who may or may not have an substance use disease in their future?

    Reply

  5. Posted by Matthew McClure, D.O. on November 2, 2017 at 4:01 pm

    Beta blockers and trauma focused treatment may prevent an acute stress reaction from progressing to PTSD. Trauma and PTSD co-occur in about 80% of my female patients and at least 50% in the males. I think the point was to prevent the problems that often lead to self medication and addiction.

    Reply

  6. Posted by Matthew McClure, D.O. on November 2, 2017 at 4:05 pm

    Is it insurance or the provider forcing the taper? If insurance can you get to a low enough dose and with the GOOD Rx coupon afford to pay for a generic or plain buprenorphine? If provider, then start looking for someone that accepts long term treatment.

    Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: