Controversies of Using Buprenorphine for Maintenance in Opioid Dependency

The use of buprenorphine for the treatment of opioid dependence is on the rise. I work with many drug and alcohol detoxification and rehabilitation programs, and in my experience, the majority of them now use buprenorphine to help patients with opioid withdrawal symptoms. The main controversy I run into is the question of when and how to taper patients off buprenorphine because it has its own withdrawal symptoms that in many cases can be as severe as symptoms of opioid withdrawal.

The idea of a “rapid taper” of buprenorphine is attractive, given the fact that patients usually have a limited time in rehabilitation, and the sooner the buprenorphine is discontinued, the more time they will have in rehabilitation without this medication. The challenge of the rapid taper is that if the patient has not had a “long enough” opioid-free period, he or she is likely to relapse. The idea of using buprenorphine as maintenance therapy, therefore, has become more popular, and recent studies indicate better outcomes with buprenorphine maintenance. Maintenance, however, is controversial because many programs and philosophies in recovery are “abstinence-based,” and some of these programs consider buprenorphine maintenance therapy as “harm reduction” rather than “abstinence.”

Research has shown that buprenorphine maintenance results in positive outcomes.¹ Despite the research findings, however, the controversies over the use of buprenorphine for maintenance are on the rise. In 2012, the Drug Enforcement Administration (DEA) found 10,804 cases of seizures linked to buprenorphine use.² According to the DEA, buprenorphine can be abused to attain euphoria through intranasal, sublingual, and intravenous routes. Furthermore, in 2011 alone, more than 20,000 emergency department visits resulted from the non-medical use of buprenorphine. Because of the high risk for abuse, overdose, and even potential death, the recovery community is often against use of buprenorphine maintenance.^3,4

As a physician who treats opioid dependence with buprenorphine, I am faced with a lot of pressure to taper my patients off buprenorphine as soon as possible. My patients who are receiving buprenorphine also face a lot of stigmatization in their recovery programs and pressure to discontinue their medications.⁵ For physicians under this kind of pressure, it is crucial to remain objective and to make the right decision for each patient. In this article, I share my decision-making algorithm.

When approaching a patient, it is important to remember that one treatment does NOT fit all patients. As usual, taking a thorough patient history of the opioid addiction and of comorbid psychiatric conditions is essential to formulating a solid treatment plan. The role of buprenorphine in the patient’s treatment can be determined on the basis of the severity of drug use (eg, intravenous vs oral; vicodin vs heroin), the length of time the patient has been opioid-dependent, the number of attempts at rehabilitation, and the number of serious overdoses. In addition, other factors, such as the patient’s living conditions, general health, and support system, are important to consider.

Addiction is a disease that requires major behavioral modifications for the patient to remain in remission regardless of whether medications are used. I recommend that all of my patients start at the highest level of care possible, meaning inpatient detoxification and rehabilitation; followed by outpatient programs; and finally joining a self-help program, such as a 12-step program or SMART Recovery for life.

Abstinence is always the main goal

I use buprenorphine for management of withdrawals only. Some individuals decide to quit using opioids on their own and do so successfully. They do not usually seek a physician’s help. If a patient is in a physician’s office asking for help, it is likely that he has been unable to quit.

Although buprenorphine induction in an outpatient setting is practiced, I generally recommend detoxification in a facility.⁶ Supervised residential detoxification is recommended because withdrawal symptoms can be severe, even when buprenorphine is used. Withdrawals can lead to relapse, and a residential detoxification setting has the support and supervision necessary to help patients through this most difficult time.

Whether the detoxification is done in an inpatient or outpatient setting, I try to taper patients off buprenorphine within the first month of sobriety. Patients usually do well with the taper until they get to about 2 to 4 mg of buprenorphine daily, and then they experience withdrawal symptoms. This approach is usually successful in patients with mild to moderate prognostic factors.

Failed attempt at abstinence

If at first I do not succeed, I try again. Some patients with opioid use disorder relapse multiple times. Just because they relapse does not mean that they are unable to abstain from using opioids. I never give up on a patient simply because he has relapsed. I send him to an inpatient program again. I encourage him to stay longer in the program and again stress the importance of doing outpatient work. I educate him about the different programs that are available and remind him of the benefits of sobriety.

I use buprenorphine to manage withdrawals just as I do in the first case. I try to keep patients in inpatient treatments longer and do a slower buprenorphine taper. Sometimes, I have patients continue buprenorphine for 2 to 3 months, and then taper slowly. My objective is to still get them off of the medication, but with more caution, because they are more likely than the first group to relapse.

Multiple failed abstinences

It is probably time to try something new. Some patients fail multiple attempts at abstinence even in the presence of optimal care. In my experience, the more severe the dependency (ie, long-term use, heavy daily use, intravenous use, severe withdrawal symptoms), the poorer the prognosis. In these cases, I keep the patient in an inpatient program for as long as possible. I try tapering buprenorphine while he is still in a residential setting, but I am open to restarting it or, alternatively, starting naltrexone injections. Naltrexone does not cause chemical dependence and is therefore safer to use. Some patients, however, are not interested in monthly injections.

Although use of both buprenorphine and naltrexone for maintenance may be controversial, I try to weigh the risks of providing these treatments against the risks of withholding them, and make decisions for each patient. Every time a patient uses opioids, he is at risk for overdosing.

Multiple failed abstinences and near-death experiences

Maintenance is probably not a bad idea. I have patients who have survived more than 10 opioid overdoses. Miraculously, they are still alive and can stay away from opioids while taking buprenorphine. Many of them have failed to remain opioid-free while taking naltrexone. As difficult as it is for a patient to take a medication long-term, in cases of multiple overdoses, I do discuss maintenance therapy. I also have a few highly functioning patients who have suffered from multiple relapses every time we tried a buprenorphine taper. However, when they continue to take their buprenorphine as prescribed, they maintain a high level of functioning. These patients are good candidates for maintenance therapy. As much as I feel pressured to discontinue their medication, I do not wish to risk taking their functionality away. Even in these extreme cases, every few months I still discuss reducing and/or discontinuing buprenorphine.

Conclusion

Although abstinence is my main goal for every patient with opioid use disorder, I recognize that every patient is an individual with unique needs. The use of buprenorphine for management of withdrawals, short-term maintenance and, in rare cases, long-term maintenance has been essential in helping many of my patients recover from their opioid use disorder.

Disclosures:

Dr Beheshti is the Founder and Medical Director of Healing Path Recovery and is also in private practice of adult psychiatry and psychotherapy in Newport Beach, Calif. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Thomas CP, Fullerton CA, Kim M, et al. Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence. 2014. http://www.asam.org/docs/default-source/advocacy/mat-with-buprenorphine-summarizing-the-evidence.pdf?sfvrsn=0. Accessed October 23, 2014.

2. Drug Enforcement Administration. Buprenorphine. July 2013. http://www.deadiversion.usdoj.gov/drug_chem_info/buprenorphine.pdf. Accessed October 23, 2014.

3. Schwartz J. The Suboxone “solution.” April 20, 2011. http://addictionandrecoverynews.wordpress.com/2011/04/20/the-suboxone-solution. Accessed October 23, 2014.

4. Sontag D. Addiction treatment with a dark side. November 16, 2013. http://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html?pagewanted=all&_r=0. Accessed October 23, 2014.

5. Matesa J. The great Suboxone debate. April 13, 2011. http://www.thefix.com/content/best-kept-secret-addiction-treatment?page=all. Accessed October 23, 2014.

6. Fudala PJ, Bridge TP, Herbert S, et al; Buprenorphine/Naloxone Collaborative Study Group. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. N Engl J Med. 2003;349:949-958.