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Addiction Medicine Services

“Addiction” does not have a simple meaning. Addictions to different drugs, or “substances,” are called substance abuse disorders. When addictive substances like opioids are taken in excess, they can activate the brain’s reward system to produce feelings of pleasure or a “high.”

The body’s reward system is normally used to reinforce behaviors and produce memories. Opiate abuse activates this normal reward system so intensely that normal activities may be neglected and forgotten about in favor of the “high” of drug use. Over time, excessive opiate use can even change the brain’s reward system so that an addicted person becomes physically dependent on the drug. Opioid addiction involves using an opioid drug compulsively, and to be overwhelmingly involved in finding, getting, and using that drug. When reducing or stopping drug use, addicted persons often experience pain and other uncomfortable symptoms (called withdrawal). Addiction also usually involves some drug tolerance, or the need to take higher doses of a drug to feel the same effects.

1. All addictions, including opioid addiction, are brain disorders. Some people, based on their heredity and environment, are more vulnerable or more likely to become addicted. Addiction is not due to lack of will power, is not a moral failing, and is not done on purpose. Often an opioid-addicted person resists treatment, but treatment options should be continuously encouraged. Relapse is also common and indicates that more or different treatments are necessary. The DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, used by psychiatrists nation-wide) organizes these problems with opioid use under the heading “Opioid Use Disorder.”

2. Buprenorphine (SUBOXONE, SUBUTEX) is used in medication-assisted treatment (MAT) to help people reduce or quit their use of heroin or other opiates, such as pain relievers like morphine.

Approved for clinical use in October 2002 by the Food and Drug Administration (FDA), buprenorphine represents the latest advance in medication-assisted treatment (MAT). Medications such as buprenorphine, in combination with counseling and behavioral therapies, provide a whole-patient approach to the treatment of opioid dependency. When taken as prescribed, buprenorphine is safe and effective.

Unlike methadone treatment, which must be performed in a highly structured clinic, buprenorphine is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in physician offices, significantly increasing treatment access. Under the Drug Addiction Treatment Act of 2000 (DATA 2000), qualified U.S. physicians can offer buprenorphine for opioid dependency in various settings, including in an office, community hospital, health department, or correctional facility.

As with all medications used in MAT, buprenorphine is prescribed as part of a comprehensive treatment plan that includes counseling and participation in social support programs.

Buprenorphine offers several benefits to those with opioid dependency and to others for whom treatment in a methadone clinic is not preferred or is less convenient. The FDA has approved the following buprenorphine products:

  • Bunavail (buprenorphine and naloxone) buccal film
  • Suboxone (buprenorphine and naloxone) film
  • Zubsolv (buprenorphine and naloxone) sublingual tablets
  • Buprenorphine-containing transmucosal products for opioid dependency

How Buprenorphine Works

Buprenorphine has unique pharmacological properties that help:

  • Lower the potential for misuse
  • Diminish the effects of physical dependency on opioids, such as withdrawal symptoms and cravings
  • Increase safety in cases of overdose

Buprenorphine is an opioid partial agonist. This means that, like opioids, it produces effects such as euphoria or respiratory depression. With buprenorphine, however, these effects are weaker than those of full drugs such as heroin and methadone.

Buprenorphine’s opioid effects increase with each dose until at moderate doses they level off, even with further dose increases. This “ceiling effect” lowers the risk of misuse, dependency, and side effects. Also, because of buprenorphine’s long-acting agent, many patients may not have to take it every day.

Side Effects of Buprenorphine

Buprenorphine’s side effects are similar to those of opioids and can include:

  • Nausea, vomiting, and constipation
  • Muscle aches and cramps
  • Cravings
  • Inability to sleep
  • Distress and irritability
  • Fever

Buprenorphine Misuse Potential

Because of buprenorphine’s opioid effects, it can be misused, particularly by people who do not have an opioid dependency. Naloxone is added to buprenorphine to decrease the likelihood of diversion and misuse of the combination drug product. When these products are taken as sublingual tablets, buprenorphine’s opioid effects dominate and naloxone blocks opioid withdrawals. If the sublingual tablets are crushed and injected, however, the naloxone effect dominates and can bring on opioid withdrawals.

Buprenorphine Safety

People should use the following precautions when taking buprenorphine:

  • Do not take other medications without first consulting your doctor.
  • Do not use illegal drugs, drink alcohol, or take sedatives, tranquilizers, or other drugs that slow breathing. Mixing large amounts of other medications with buprenorphine can lead to overdose or death.
  • To ensure that a physician monitors any liver-related health issues that you may have.

Pregnant or Breastfeeding Women and Buprenorphine

Limited information exists on the use of buprenorphine in women who are pregnant and have an opioid dependency. But the few cases reports available have not demonstrated any significant problems resulting from the use of buprenorphine during pregnancy. The FDA classifies buprenorphine products as Pregnancy Category C medications, indicating that the risk of adverse effects has not been ruled out.

Treatment with Buprenorphine

The ideal candidates for opioid dependency treatment with buprenorphine:

  • Have been objectively diagnosed with an opioid dependency
  • Are willing to follow safety precautions for the treatment
  • Have been cleared of any health conflicts with using buprenorphine
  • Have reviewed other treatment options before agreeing to buprenorphine treatment

Before buprenorphine treatment begins, policies and procedures should be in place to guarantee patient privacy and the confidentiality of personally identifiable health information. Under the Confidentiality Regulation, 42 Code of Federal Regulations (CFR) 2, information relating to substance use and alcohol treatment must be handled with a higher degree of confidentiality than other medical information.

Buprenorphine treatment happens in three phases:

1. The Induction Phase is the medically monitored startup of buprenorphine treatment performed in a qualified physician’s office or certified OTP using approved buprenorphine products. The medication is administered when a person with an opioid dependency has abstained from using opioids for 12 to 24 hours and is in the early stages of opioid withdrawal. It is important to note that buprenorphine can bring on acute withdrawal for patents who are not in the early stages of withdrawal and who have other opioids in their bloodstream.

2. The Stabilization Phase begins after a patient has discontinued or greatly reduced their misuse of the problem drug, no longer has cravings, and experiences few, if any, side effects. The buprenorphine dose may need to be adjusted during this phase. Because of the long-acting agent of buprenorphine, once patients have been stabilized, they can sometimes switch to alternate-day dosing instead of dosing every day.

3. The Maintenance Phase occurs when a patient is doing well on a steady dose of buprenorphine. The length of time of the maintenance phase is tailored to each patient and could be indefinite. Once an individual is stabilized, an alternative approach would be to go into a medically supervised withdrawal, which makes the transition from a physically dependent state smoother. People then can engage in further rehabilitation—with or without MAT—to prevent a possible relapse.

Treatment of opioid dependence with buprenorphine is most effective in combination with counseling services. Counseling is available at each visit. Counseling is recommended for every patient but is not mandatory. If you are having trouble with continued use of drugs while on Suboxone or Subutex, we will provide more frequent counseling (weekly or biweekly) free of charge. Some patients may be referred for intensive outpatient services or inpatient services if reasonable efforts to stop destructive drug use fails.

Methadone to Buprenorphine

Patients can possibly switch from methadone to buprenorphine treatment, but because the two medications are so different, patients may not always be satisfied with the results. Studies indicate that buprenorphine is equally as effective as moderate doses of methadone. However, because buprenorphine is unlikely to be as effective as more optimal-dose methadone, it may not be the treatment of choice for patients with high levels of physical dependency.

A number of factors affect whether buprenorphine is a good choice for someone who is currently receiving methadone. Patients receiving buprenorphine can possibly be switched to methadone.