Below is an e-mail that I changed just enough to hide the person’s identity.  every week, I receive messages that describe similar situations.

My husband has struggled GREATLY with substance abuse since in his 20′s; he is now in his mid-40′s. He is the kindest sweetest man and he is the BEST husband and father. When he is using he becomes someone he is not. We have run the gamut from jail to overdose.  Six years ago a friend introduced him to Suboxone and it LITERALLY gave him his life back. He bought it off the friend for years, where it was very expensive. Finally I brought him to a doctor a bit over a year ago. she is pretty adamant about weaning him off of Suboxone.

From experience, I know that 2-3 months after he stops Suboxone he will relapse. I strongly believe it IS a MIRACLE drug! I agree in the sense that if a diabetic needs insulin to save his life, you give it for a lifetime. my husband over the last 6 years has been the man of my dreams, the man I always knew he was. I have extreme anxiety because I know this doctor is just doing her job and trying to follow guidelines however my husband’s LIFE is at stake!  It’s not like if he stops this med he could ‘just’ have depression;  he could end up in jail, or worse. He has his life back. He is enjoying his family life as he should.

If this is what it takes for him to live a normal life then why not?  When we ask his doctor about staying on Suboxone, she says her concern is that we don’t know the long-term effects. she doesn’t want to keep anyone on any med without knowing what it could do. she says it hasn’t been on the market long enough. 

My husband had a SEVERE opioid addiction. He was taking 10-15 Oxycontin 80mgs a day and then ended up switching to 400mgs of methadone before he switched to Suboxone. He has found that he is comfortable with 4 of the 8mg pills per day. I believe it is because he was used to taking such high doses of opioids. He has tried really hard to decrease Suboxone for his doctor but I see the anxiety build in him. she says no one in her practice is on that dose. to be honest he was taking more when he was buying them from a friend but brought himself to a stable 4 pills per day when he started with the doctor. He and I both REALLY like her and would like to continue treatment with her. I wish I had a DVD of little clips of our life from before and after Suboxone. I am positive she would be floored. I am positive she would understand my concern. in my eyes my husband is back. He is such a beautiful soul and I hate to see that taken away from him yet again.

Doctor I read up at the top of this blog that you agree with a lifetime use. He currently has no noted side effects. do you have any suggestions that I may present to his doctor? I dream of the day that she says it is alright for him to continue on this until maybe he chooses to wean if he so chooses to do so. that would alleviate SO MUCH stress on both of us. Please let me know what you think.

Anyone who reads this blog knows that I agree with most of the opinions expressed in the email.  I know how horrible things are for active opioid addicts—and for the families of active opioid addicts.

More and more physicians pay lip service to ‘addiction as a disease,’ but most do not yet treat addiction as a disease.  the comments about diabetes are ‘right on.’ one could substitute a number of diseases to demonstrate the same point.  We physicians have few illnesses that we cure; rather we manage illness over a person’s lifetime— and opioid dependence is clearly a life-long illness.

To address a couple points in the message:  the active ingredient in Suboxone, buprenorphine, has been in clinical use for over three decades, and has established a clean safety profile.  Buprenorphine has not been used at the high doses employed for treating opioid dependence for quite as long, but even that track record is significant, i.e. 8 years in this country, and longer in Europe.  most physicians would not consider an 8-yr-old medication to be a ‘new drug!’

The situation described in the message is, in my opinion, the result of several factors.   First and foremost, the reluctance to prescribe buprenorphine is a consequence of stigma.  Doctors prescribe new antidepressants, pain relievers, blood pressure treatments, and cholesterol-lowering agents with much less concern over ‘safety.’     I wonder, frankly, if safety is the concern—or whether there is an unconscious sense that patients addicted to opioids, or to other substances, don’t deserve an ‘easy way out’ of their problem; that sitting through a miserable detox is  a more fitting ‘treatment’ than a pill that makes things better.

I come to this cynical conclusion only because the alternative—that buprenorphine is ‘dangerous’—doesn’t make sense.  the risk of any medication must be compared against the risk of not using that medication.  As the message states, we know the risk of ‘not treating’ the woman’s husband!  Similar comparisons are used to justify the use of chemotherapeutic agents that have severe toxic effects, including the risk of killing the patient.  As I’ve written in prior posts, the fatality rate from untreated opioid dependence is as high as for many cancers.  so does it make any sense to withhold buprenorphine out of safety concerns?!

There are other reasons for doctors’ reluctance to prescribe buprenorphine. Many fear they will do something wrong, and run afoul of the DEA during an audit—a process that all buprenorphine-certified prescribers are subject to.   Some doctors feel pressure from friends and family members of patients, who often blame the doctor for keeping the patient ‘stuck on Suboxone.’  Some doctors want to maintain high patient turnover in order to keep money  coming in, since practices are ‘capped’ at 100 patients per certified physician.

Finally, I think many doctors see ongoing treatment as less satisfying than a ‘cure.’  They consider residential treatment the gold standard, and buprenorphine as a less-intensive alternative.  They buy into the idea that the addict can be returned to ‘normal’—whatever that is—if he/she works at recovery hard enough.  I understand the thought, as that is the type of treatment experience that I went through.  But on the other hand, the relapse rate for opioid dependence, after residential treatment, is very high. I myself relapsed after seven years of recovery, losing my career, and almost my life.  during my years as medical director of a large residential treatment center, patients discharged as ‘successfully treated’ often became repeat customers, at least until they lost their job and health insurance.  Some of them– too many of them–died.

I won’t get into the specifics of treatment;  I’ll leave that to her husband’s doctor to work out.  But I do hope that the doctor will give some thought to whether stopping this life-saving treatment is truly in the patient’s best interest.

To the patient’s wife– I encourage you to continue as an advocate, and I hope your doctor will understand your perspective.

Worried woman photo available from Shutterstock.

I am a Psychiatrist and PhD Neuroscientist in solo, private practice in NE Wisconsin. I treat adults, children and adolescents for all psychiatric conditions, with an emphasis on improving the strength of the doctor/patient relationship through longer appointments, greater access, and frequent e-mail communication. I teach psychiatry at the Medical College of Wisconsin, and provide psychiatric servicies for the U of WI Oshkosh Campus. Finally, I provided expert witness testimony for a wide range of cases related to psychiatry, neurology, addiction, and chronic pain. I am Board Certified by the American Board of Psychiatry and Neurology, and lifetime-Board Certified by the American Board of Anesthesiology.

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    Last reviewed: 2 Jan 2012 APA ReferenceJunig, J. (2012). When to stop Treatment? Why?. Psych Central. Retrieved on January 4, 2012, from blogs.psychcentral.com/epidemic-addiction/2012/01/when-to-stop-treatment-why/

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San Jose, CA (OPENPRESS) December 10, 2011 – Opioids, which are among the oldest known drugs in the world, is acknowledged for its therapeutic benefits and analgesic or painkiller effects. Opiate drugs are designed to alter the behavior areas of the brain that are known as “opioid receptors. as such, Opioid drug addiction, which develops almost unconsciously, can happen with just a week of regular use and with severe withdrawal symptoms. The Drug Addiction Treatment Act of 2000 or DATA recommends the Suboxone treatment for people who have diagnosed as dependent on or addicted to Opioid. The active ingredient in Suboxone is a partial opioid agonist. Suboxone-Doctor.com is a website that tackles the sensitive subject of substance addiction, with particular emphasis on Opioid dependency. created January 2008, the website is focused on providing relevant information about opioid addiction and recommending safe and healthy recovery options. Suboxone-Doctor.com incorporates a forum section, the Suboxone Doctor Help Spot, which has been a place where patients and potential patients could ask questions, share their stories, and get honest advice and feedback from other people in similar situations. at the forum, there is no judgment, and privacy is respected. In its quest to continuously provide relevant assistance to visitors, Suboxone-Doctor.com expands the website with the addition of a directory listing that helps people find Suboxone doctors in their area who specialize in the use of Suboxone and that can offer help with Suboxone withdrawal. The directory features top Suboxone physicians who excel in the field, while helping patients locate physicians in their state. at Suboxone-Doctor.com/Physician, visitors will also find helpful articles that talk about the different versions of the Suboxone drug, side effects of Suboxone, the different therapies being tried, and other information about what’s new, interesting, and innovative in this field. Topics covered include Heroin addiction, Heroin detox using Methadone, Buprenorphine and Opiate rehab and Vicodin detox. Individuals looking to learn about Opioid addiction and recovery through Suboxone, as well as find specialists who can help should visit suboxone-doctor.com and browse the comprehensive doctor directory and information resource.Original Source: Suboxone Doctors Directory Newly Launched as part of Suboxone Community Forum, Suboxone-Doctor.com

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Author name: Barthell L.R. Crilly

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Close to a million individuals in US are addicted to opioids and yet less than 20% receive any treatment for their addiction. The best management for these chronic addicts is medical treatment which decreases their addiction and improves their social status in society.

For the past 4 decades, methadone has been the treatment of choice for the treatment of drug addicts . However, all methadone programs have long waiting lists; have rigid admission criteria and the majority of methadone programs are only found in large urban cities. Current data indicate that buprenorphine, which is a partial opioid receptor agonist, may also be effective for treatment of opioid addiction.

The Drug Addiction Treatment Act of 2000 allowed physicians to provide office-based treatment for opioid addiction. This Federal Legislation allowed physicians to prescribe Schedule III, IV, or V “narcotic” medications that were approved by the U.S. Food and Drug Administration for patients with opioid addiction. In 2002, the FDA approved buprenorphine and combination of buprenorphine/naloxone (Suboxone) to manage opioid dependence.

Buprenorphine (Suboxone)

Buprenorphine, is an opioid drug with partial agonist and antagonist activity. Buprenorphine was first marketed in the 1980s as an analgesic, yet today it is primarily used for the treatment of opioid addiction. It has a longer duration of action than morphine, and sublingual administration offer an analgesic effect which lasts 6 to 8 hours. because the drug cannot be reversed by naloxone, it is not recommended for pain control.

When used for opioid dependence, buprenorphine remains effective in the body for up to 48 hours, decreases the tendency for withdrawal symptoms and counteracts the effects of concomitant opioids that may be taken by the patient.

Side Effects

Buprenorphine does have some side effects and these include nausea, vomiting, drowsiness, dizziness, headache, itch, dry mouth, meiosis, orthostatic hypotension, difficulty with ejaculation, decreased libido, urinary retention, and constipation. Rare cases of liver necrosis and hepatitis with jaundice have been reported with the use of buprenorphine. for those who receive buprenorphine, the liver function is regular monitored. The most severe and serious adverse reaction associated with buprenorphine use is respiratory depression which can be fatal. This is particularly problematic with buprenorphine because unlike morphine, there is no effective antidote.

Additionally, concurrent use of buprenorphine and CNS depressants (such as alcohol or benzodiazepines) is contraindicated as it may lead to fatal respiratory depression.

Dependence

As with other opioids, buprenorphine can produce both physical and psychological dependence. However, unlike other opioids, users of buprenorphine rarely develop a tolerance to the drug. Maintenance dosages can remain at the same moderate level and in many cases even lowered, without causing withdrawal symptoms.

Treatment of Opioid Dependence

Sublingual buprenorphine preparations are often used in the management of opioid dependence (such as heroin, oxycodone, hydrocodone, morphine). The use of buprenorphine replacement therapy in the management of opioid dependence is regulated and monitored. In the United States, a special federal waiver is required to prescribe Subutex on an outpatient basis. Each Federally approved physician is allowed to manage only 30 patients on buprenorphine for opioid addiction as outpatients.

Withdrawal Symptoms

The partial agonist/antagonist activity of buprenorphine means that it may precipitate withdrawal symptoms when an opioid-dependent patient is commenced on the drug soon after the use of another opioid drug. Patients are advised to wait between 24 and 36 hours after their last use of short-acting opioids (such as heroin or oxycodone) before beginning treatment with buprenorphine. those who are on methadone should only be treated with buprenorphine once withdrawal symptoms are present. Beginning any earlier may result in extreme cases of opioid withdrawal.

BUPRENORPHINE vs. METHADONE

Buprenorphine and methadone are both used for short-term and long-term opioid maintenance therapy. Each agent has its relative advantages and disadvantages.

Buprenorphine sublingual tablets have a long duration of action which may allow dosing every two days, compared with the daily dosing required with methadone. In the United States, following initial management, a patient may be prescribed one month supply for self-administration on the condition that the patient receives other dependence therapy.

Buprenorphine may have a lower dependence-liability than methadone. Buprenorphine treatment typically lasts several months (though sometimes for only a few weeks or up to two or three years), as opposed to an indefinite, often life-long methadone regimen.

Buprenorphine itself appears to have less-severe withdrawal effects than methadone, and thus it is easier to discontinue use. Buprenorphine, as a partial μ-opioid receptor agonist, has been claimed to have a less euphoric effect compared to the full agonist methadone, and was therefore predicted to be less likely to be diverted to the black market.

DETOX AND REHABILITATION

The practice of using buprenorphine in an inpatient rehabilitation setting is increasing rapidly. these rehabilitation programs consist of “detox” and “treatment” phases. The detoxification phase consists of medically-supervised withdrawal from the drug of dependency, sometimes aided by the use of medications such as buprenorphine and valium.

Buprenorphine is sometimes used only during the detox protocol with the purpose of reducing the patient’s use of mood-altering substances. It considerably reduces opioid withdrawal symptoms that are normally experienced by opioid-dependent patients on cessation of those opioids, including diarrhea, vomiting, fever, chills, cold sweats, muscle and bone aches, muscle cramps and spasms, restless legs, agitation, gooseflesh, insomnia, nausea, watery eyes, runny nose and post-nasal drip, nightmares, etc. The buprenorphine detox protocol usually lasts about 7-10 days, provided that the patient does not need to be detoxed from any additional substances such as barbiturates, benzodiazepines, or alcohol.

Dosing

During detoxification Buprenorphine is administered on a daily basis. Generally, the patient receives a single dose each day to ensure a consistent active level of the medication remains in the patient’s central nervous system. Typically, the initial daily dose totals around 8-16mg. The dosage is slowly tapered each day and the medication is usually stopped 36-48 hours prior to the end of the detox program, with the patient’s vitals monitored up until discharge from the detox program.

Summary

Buprenorphine is an alternative and not a replacement agent for methadone in patients with opioid dependence for opioid agonist therapy in patients with opioid dependence. Buprenorphine is viable in the primary care setting, which enhances treatment accessibility, and may be a better initial choice for patients at greater risk of respiratory depression, such as elderly patients and those taking benzodiazepines. Choice of first-line treatment will depend on patient preference, expectations, past treatment experiences and side effect profile as well as availability, dispensing regulations, cost and government reimbursement schedules. However, regardless of choice of methadone or buprenorphine, patients with opioid dependence do best in a comprehensive program involving opioid agonist treatment, counseling and support.

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Has anyone been to a ultra rapid detox program where they put you under and when you wake up you have no withdraw symptoms. from the drug you where using? or has anyone gone through any other type of program that does require suboxone as part of there program?

No and, never heard of it.

I've heard great things about Suboxone. there is still some withdrawal at the end stages but while on the Sub you have no cravings and no withdrawal. after time, they ween you down until withdrawal is minimal.

As for the rapid detoxification, Its VERY expensive. also, a LOT of people relapse after it.

I've been taking opiates for the last three years – they are a blessing and a curse at the same time.

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