Posts Tagged ‘Suboxone’

Suboxone: Miracle Drug or Manacle?

Yesterday in my office, I saw patients for whom I prescribe buprenorphine (better known under the brand name Suboxone). It was not my typically pleasant day. Usually, I see the positive changes occurring in the lives of my patients: they are getting families back, getting jobs or better jobs, getting health and dental care needs addressed, and overall feeling happier and more productive.

 But yesterday I had two patients who were bitter about being on Suboxone. Both were having great difficulty tapering off of Suboxone. Both had also been reading materials on the internet that described the hopelessness of ever tapering off this medication.

 This frustrates me for several reasons. First, not everything you read on the internet is correct. Second, people don’t appear in my clinic requesting Suboxone for no reason. All of my Suboxone patients were addicted to opioids before I ever prescribed Suboxone. Even assuming no patient ever gets off Suboxone, it’s still so much better than what they were doing before. Third, I’ve never said it’s easy to get off Suboxone. It can be done, but it’s still an opioid. When you stop opioids, you will have withdrawal. There’s no way around that. 

Overall, most people say withdrawal off Suboxone is easier than other opioids. But people and their biochemistries are different, and I accept that some people have a worse withdrawal than other people. I’ve had a few people say methadone withdrawal was easier than Suboxone withdrawal. I have to believe that’s their experience, but I think that’s unusual, and not the experience of most people. 

Some doctors think patients on maintenance medications, like methadone or Suboxone, should always stay on these medications, given what we know about the rates of relapse and even death for patients who leave these programs. And some patients have continued sub acute withdrawal symptoms for weeks or months off opioids, and just don’t feel right unless they are on maintenance medications. These people seem to do better if they stay on maintenance medication. 

And on the other hand, many people are able to taper off opioids and remain off of them, and lead happy, healthy lives. I keep thinking about two groups of recovering opioid addicts who do well off of all opioids, on no maintenance medications: members of 12-step recovery groups, and recovering medical professionals.

 Off the top of my head, I can think of a dozen recovering opioid addicts who are members of Alcoholics Anonymous or Narcotics Anonymous, and who aren’t on any maintenance medications. They feel fine, and have been abstinent from opioids for years. If you don’t believe me, go to an open Narcotics Anonymous meeting. Ask the recovering addicts there if they have been addicted to opioids in the past. Chances are that around a fourth of the people you talk to are recovering from opioid addiction. There may be a few people who are on methadone or Suboxone, but many are completely free from opioids.

 Look at doctors in recovery. Opioids were the drug of choice for many addicted doctors, and they are “real” addicts, having used remarkable amounts of opioids before getting into recovery. But doctors have one of the highest rates of drug-free recovery. This isn’t because we are so smart or special, or because we have Charlie Sheen’s tiger blood. It’s because we are held tightly accountable by our licensing boards. If we want to practice medicine, we have to participate in recovery. Licensing boards often hold our licenses hostage unless we do the work of recovery. This may mean three to six months of inpatient residential treatment, after a medical detoxification. It may mean four recovery meetings per week for the first five years of recovery, along with monthly random drug screen, and a monitoring contract for five years.  (1,2)

If every addict seeking recovery could have that degree of treatment and accountability, I suspect relapse rates would be uniformly low. Sadly, that’s just not possible for most opioid addicts, because of financial constraints, and because there’s less leverage with most people than with licensed professionals. 

Not all opioid- addicted doctors do great off opioids. Many have multiple relapses, and would probably be much healthier and happier if they got on maintenance medications like methadone or Suboxone, but isn’t allowed – at present – by the licensing boards in most states. Again, one type of treatment doesn’t work for everyone.

 My point is that it is possible for many people to get off Suboxone, and live a happy drug free life. And for other people, lifelong maintenance is probably the best and safest option. At present, we don’t have a way to predict who might do well off of Suboxone (or methadone). We do know that a taper should be slow, and probably takes four to six months for a taper to give best results.

 I believe in Suboxone. It’s saved many lives, just like methadone has. I wouldn’t prescribe it if I didn’t know it works. I think what I’ve been hearing and reading is a normal backlash against the unrealistic expectations many people had for Suboxone. It’s been called a miracle drug, but it’s not. It’s still an opioid, and there is still a withdrawal when it’s stopped. It’s a great medication for many people. It can allow many opioid addicts to get their lives back and enjoy a normal life, except for having to take a daily dose of Suboxone. But isn’t that still drastically better than active addiction? 

  1. Ganely, Oswald H, Pendergast, Warren J, Mattingly, Daniel E, Wilkerson, Michael W, “Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000,” Journal of Addictive Diseases, Vol 24(1) 2005.
  2. McLellan, AT, Skipper, GS, Campbell, M, DuPont, RL, “Five Year outcomes in a cohort study of physicians treated for substance abuse disorders in the United States,” British Medical Journal,2008;337: a 2038.
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New Form of Suboxone: Dissolving Film

Yesterday the FDA approved a new delivery system for the medication buprenorphine. Reckitt Benckiser, the drug company that makes the brands Suboxone (a combination pill of buprenorphine and naloxone) and Subutex (containing only buprenorphine), is now approved to manufacture and sell Suboxone in the form of a thin film that is placed under the tongue to be absorbed. According to early studies, patients think the film tastes better, dissolves more quickly, and is easier to use. I don’t yet have any information on the relative cost of this new film.

Since it was just approved, it’s not likely that a generic form of the film will be available for many years.

 This film of buprenorphine, the active ingredient, can’t be obtained as a generic, and it may be a few weeks before it appears in retail pharmacies.

 I’m hoping the sublingual (under the tongue) film will be harder to snort or inject, because there are reports of addicts misusing the Suboxone and Subutex tablets. And every addict misusing the name brands or the generic of buprenorphine who comes to the attention of law enforcement endangers the existence of the buprenorphine program.

 In the past I worried about prescribing Subutex, the form of the drug that doesn’t contain naloxone, or the newer generic buprenorphine, which also doesn’t contain naloxone. But apparently, some addicts are able to inject Suboxone, and the naloxone in it doesn’t put them into withdrawal. At least, they don’t go into intolerable withdrawal.

 It just shows me again that people are so different in the way they react to medications.

Which is better, Suboxone or methadone?

 

Patients often ask which medication is better to treat opioid addiction: methadone or Suboxone? My answer is…it depends.

 First of all, the active drug in Suboxone is buprenorphine, and I’ll refer to the drug by its generic name, since a generic has entered the market. We’re no longer just talking about one name brand.

 The principle behind both methadone and buprenorphine is the same: both are long-acting opioids, meaning they can be dosed once per day. At the proper dose, both medications will keep an opioid addict out of withdrawal for 24 hours or more. This means instead of having to find pain pills or heroin to swallow, snort, or shoot three or four times per day, the addict only has to take one dose of medication. Addicts can get back to a normal lifestyle relatively quickly on either of these medications. Both methadone and buprenorphine are approved by the FDA for the treatment of opioid addiction, and are the only opioids approved for this purpose.

Buprenorphine is safer then methadone, since it’s only a partial opioid. A partial opioid attaches to the opioid receptors in the brain, but only partially activates them. In contrast, methadone attaches to opioid receptors and fully stimulates them, making it a stronger opioid. Because buprenorphine is a partial opioid, it has a ceiling on its opioid effects. Once the dose is raised to around 24mg, more of the medication won’t have any additional effect, due to this ceiling. But with methadone, the full opioid, the higher the dose, the more opioid effect.

 Because buprenorphine is a safer medication, the government allows it to be prescribed in doctors’ offices, but only if the doctor has taken a special training course in opioid addiction and how to prescribe buprenorphine, or can demonstrate experience with the drug. This office-based treatment of addiction has a huge advantage over treatment at a traditional methadone clinic. Treatment in a doctor’s office doesn’t have to follow the strict governmental regulations that a methadone clinic must follow. Methadone clinics have federal, state, and even local regulations they must follow, and patients have to come to the clinic every day for dosing, until a period of months, when take home doses can be started for weekends.

 The law allowing buprenorphine to be prescribed for opioid addicts from offices instead of clinics was passed in 2000. It was hoped that relatively stable opioid addicts would get treatment at doctors’ offices, and addicts with higher severity of addiction would still be treated at methadone clinics.

 But it hasn’t worked out quite like that. Because buprenorphine is relatively much more expensive than methadone, addicts with insurance or money go to buprenorphine doctors’ offices, and poor addicts without insurance go to methadone clinics. Rather than form of treatment being decided by severity of disease, it’s decided by economic circumstance. This means that some of the opioid addicts being treated through doctors’ offices really aren’t that stable, and have been selling their medication, making it a desirable black market drug. Most of the addicts buying illicit buprenorphine have been trying to avoid withdrawal or trying the drug before paying the expense of starting it.

 Treating opioid addicts for the last nine years, I’m continually surprised at how people’s physical reactions to replacement medications are dissimilar. Some patients don’t feel well on buprenorphine, but feel normal on methadone. For other patients, it’s just the opposite. For many, either medication works well.

 Addicts (and their doctors) tend to assume that all opioid addicts will be the same in their physical reactions to these replacement medications, but they aren’t. For example, last week I saw a lady who insisted she’s never had physical withdrawal symptoms from methadone. But most patients find methadone withdrawal to be the worst of all opioids.

 And sometimes I have a patient I expect will do very well on buprenorphine, but they don’t. they feel lousy.

 So the answer to question of which medication is best – buprenorphine is safer, and not as strong an opioid, so it’s the preferred medication. It’s also more convenient, but much more expensive at present. But a great deal depends on the patient, and how she reacts to medications.

 Neither medication is meant to be the only treatment for opioid addiction. Best results are seen when these medications are used along with counseling, to help the addict make necessary life changes.

Interview with a Suboxone Doctor

The following is an interview with one of the first prescribers of Suboxone in Charlotte, North Carolina. Dr. George Hall is an experienced physician, board certified in both Family Practice and Addiction Medicine, who has worked in both fields for many years and helped countless addicts and their families:

JB: What have your experiences been, treating opioid addiction with buprenorphine, or Suboxone?

GH:   It’s been pretty incredible from day one…….watching people, and the difference it’s made in their lives, when they come on buprenorphine.

JB: Of the patients you’ve started on buprenorphine, what percentage would you say improved on it?

GH: Ninety-plus percent, I would think. You’ll have the occasional patient who doesn’t come back, and an occasional patient who can’t afford it, but there’s not many that stand out in my mind through the years [who have done poorly with buprenorphine].

JB: Can you describe how you decide to do a detoxification with a patient on buprenorphine, versus keeping the patients on it for longer, and what your experiences have been?

GH: The people I detox on buprenorphine are the ones who have to come off of it in a short period of time. They say, “I want off by one month or two months or three,” and generally those people actually change their mind over a period of time, as they see their life getting better.

So, most of the time, it’s patient-driven. As you know, the data for opiate dependency shows that this population just doesn’t seem to do very well. Perhaps that’s the reason I have such a positive feeling about buprenorphine. We’ve used it for maintenance, since day one, in a lot of patients, and those are the people whose lives you see continue to change over a long period of time.

JB: Are there any problems that you’ve seen with buprenorphine?

GH: I think the problem with buprenorphine is similar to the problem with methadone …we see these people getting extremely well. They don’t get euphoric, but they’re not ill any longer. They’re able to function, they’re able to sleep. It’s a long-acting medication that allows them to have a normal day. When they’re out on the street or they’re buying from the internet or they’re going to multiple doctors, they just don’t have normal days.

So is that a problem? Only if you define any sort of recovery as abstinence-based. But, if you’re defining recovery as improvement in quality of life, not using other substances, able to hold jobs, able to have families and interact with families, treat their depression, then these people do extremely well.

But…I think the problem for me is…..once they begin to do so well, it’s just like with anything else, whether it’s an alcoholic or a cocaine addict or a marijuana addict that’s been in recovery for a period of time. The acuity of the disease drops in the patient’s mind, and it seems like they think, “I’m cured,” and “I’m just normal now so I don’t need to do other things. I don’t need to go to NA meetings. I don’t need counseling. Why do you keep pushing me to do this, because I haven’t used in two years? I’m doing great.”  Whether this is the disease talking to them or it’s just part of life…

And that’s what I see with any addiction…the disease itself says you don’t have a disease, whether it’s alcohol dependency or opiate dependency, and perhaps we see that even more with opiate dependency. We see that on maintenance therapy.

JB: If you had an opiate addicted patient who had unlimited money, time, willingness, and resources, what treatment would you recommend first? If they were addicted only to opiates?

GH: When I think about that question, I think about gold standards of treatment. The people who have the highest recovery rates are professionals. Physicians in North Carolina have over a ninety percent recovery rate at five years. It’s not because they’re physicians, it’s not because they’re brilliant, it’s because they’re made to do a lot of stuff to help convince them they have an illness, and to treat it as an illness on an ongoing basis. They are made to do at least twenty-eight days, to three months, to six months of inpatient treatment, most of them from the beginning. If we had an IV opiate-addicted anesthesiologist, [he would get] probably at least twelve weeks of inpatient treatment, monitoring, and perhaps even a job change. So [addicted doctors] do extremely well. Not that they have unlimited funds, but if they want to remain a physician, they have to do certain things.

So that kind of brings me around to what you’re asking. If money were no object, I would think fairly long term – two to four months of inpatient treatment, with a slow detox with something such as buprenorphine, which is a very soft detox compared to some of the ones we’ve used in the past – followed up by intensive group therapy,  and then getting them involved in 12-step recovery programs. And after we bring them out of inpatient treatment, [they would get] some sort of follow up over a period of one to two years if we are looking at unlimited funds, and the willingness to do that. Which isn’t practical in the general population.

JB: Because of the expense and time?

GH: Because of the expense and the time we have.

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

Urine Drug Screens for methadone and Suboxone (buprenorphine)

Many patients who are prescribed methadone or buprenorphine (better known to some as Suboxone) are concerned about their employment drug screens. Because of the stigma attached to opioid addiction and its treatment with methadone or buprenorphine, patients don’t want their employers to know about these medications, and thus about their history of addiction.

Most companies who do urine drug screening hire a Medical Review Officer (MRO), who is a doctor specifically trained to interpret drug screen results. This doctor is a middle man between the employer and the employee, and though this doctor may ask for medical information, and information about valid prescriptions, this doctor usually can’t tell the employer this personal information. The MRO reports the screen as positive or negative, depending on information given to her.

Most employment urine drug screens check for opiates, meaning naturally-occurring substances from the opium poppy, like codeine and morphine. Man-made opioids like methadone, buprenorphine, and fentanyl, to name a few, won’t show as opiates on these drug screens.

A few employers do drug screening that specifically checks for hydrocodone or oxycodone. This is infrequent. It’s rare for employers to screen for methadone, and they almost never screen for buprenorphine, unless the patient is a healthcare professional being monitored by a licensing agency. The screen for buprenorphine is pricey, so the only doctors who tend to screen for it regularly are the ones prescribing buprenorphine. These doctors want to make sure their patients are taking, not selling, their medication.

Patients ask if they should tell their employer they are on methadone or buprenorphine. In general, that’s probably a bad idea, unless it’s a special situation. So long as you can do your job safely, your medical problems aren’t any of your boss’s business.

The only exceptions to this are if you work in a “safety sensitive” job. This includes medical professionals, transit workers, pilots, and the like. These jobs may require disclosure of medical issues to protect public safety. For example, to get a commercial driver’s license (CDL), you have to be free from illnesses which may cause a sudden loss of consciousness behind the wheel.

The Dept. of Transportation still says that if you are taking methadone for the treatment of addiction, you can’t be granted a CDL. However, most of the studies done on methadone-maintained patients shows their reflexes are the same as a person not on methadone, so there’s no real scientific reason for the DOT’s decision. (1, 3, 4) Besides, since the urine drug screen for a driver’s physical doesn’t include methadone, they won’t know unless you tell them.

Patients can be impaired, and unable to drive safely, if they have just started on methadone, haven’t become accustomed to it, or are on too high a dose. These patients shouldn’t be behind the wheel until they are stable, even in a car, let alone an 18-wheeler. Methadone patients are likely be impaired and unable to drive if they abuse benzodiazepines. They shouldn’t drive any kind of vehicle. Ditto for alcohol. (2, 5)

1. Baewert A, Gombas W, Schindler S, et.al., Influence of peak and trough levels of opioid maintenance therapy on driving aptitude, European Addiction Research 2007, 13(3),127-135. This study shows that methadone patients aren’t impaired at either peak or trough levels of methadone.

2. Bernard JP, Morland J et. al. Methadone and impairment in apprehended drivers. Addiction 2009; 104(3) 457-464. This is a study of 635 people who were apprehended for impaired driving who were found to have methadone in their system. Of the 635, only 10 had only methadone in their system. The degree of impairment didn’t correlate with methadone blood levels. Most people on methadone who had impaired driving were using more than just methadone.

3.Cheser G, Lemon J, Gomel M, Murphy G; Are the driving-related skills of clients in a methadone program affected by methadone? National Drug and Alcohol Research Centre, University of New South Wales, 30 Goodhope St., Paddington NSW 2010, Australia. This study compared results of skill performance tests and concluded that methadone clients aren’t impaired in their ability to perform complex tasks.

4.Dittert S, Naber D, Soyka M., Methadone substitution and ability to drive. Results of an experimental study. Nervenartz 1999; 70: 457-462. Patients on methadone substitution therapy did not show impaired driving ability.

5.Lenne MG, Dietze P, Rumbold GR, et.al. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol on simulated driving. Drug Alcohol Dependence 2003; 72(3):271-278. This study found driving reaction times of patients on methadone and buprenorphine don’t differ significantly from non-medicated drivers; however, adding even a small amount of alcohol (.05%) did cause impairment.

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.