Switching to methadone as a tapering strategy
Another option is to switch your patient to a different opiate before doing the taper. One reason to do this is to interrupt the positive associations a patient might have made with a particular drug. In addition, switching to a longer-acting drug makes for less frequent dosing. The fewer daily choices people have between taking or not taking something, the more successful they’ll be in following a tapering schedule. For example, one approach is to switch a patient from Vicodin to methadone, which has advantages because it is inexpensive, longer acting, and produces less euphoria than many of the other opioids. Not every pharmacy carries it, but many do, and it comes in a variety of forms, including liquid as well as tablets of different strengths.
Contrary to popular belief, you do not have to be part of a federally licensed treatment center to prescribe methadone. Any provider with a DEA license to prescribe Schedule II substances can prescribe methadone—as long as you are clear in your documentation that you are prescribing it for pain rather than for treatment of narcotic abuse. However, if the patient’s opiate use is not related to pain, you will need to either refer to a narcotic treatment program for methadone maintenance or to a buprenorphine provider for office-based opioid treatment.
Conversion tables are available to help you determine the right dose of methadone to use when transitioning from opioids like hydrocodone or oxycodone. For example, see the Methadone Conversion and Dosing Information table online at http://www.iadur.org/sites/default/files/ghs-files/methadonedosing.pdf.
On a cautionary note, since methadone is long-acting, patients may not notice the effects as quickly as they are used to, and might be tempted to take extra doses initially. The danger is that these doses can catch up to them all at once, and people may accidentally overdose on methadone because of their inexperience in using it.
Buprenorphine for maintenance or detox treatment
Buprenorphine is a semisynthetic opioid that has been available as a narcotic since 1981. It has long been used as an option for treating severe pain and comes in different forms, including injectable, sublingual, and as a skin patch.
How did buprenorphine end up playing such a central role in treating opiate abuse? Unlike all other opiate products such as codeine, hydrocodone, oxycodone, methadone, and even heroin, buprenorphine is an opioid agonist/antagonist. The agonist property activates opioid receptors, while the antagonist property tends to modulate that activation. For this reason, the medication helps patients feel normal rather than high.
The bottom line is that buprenorphine, with its push/pull agonist/ antagonist properties, is less likely to be abused than its opiate cousins. This in itself makes it a good choice for maintenance treatment. The buprenorphine mono product (without naloxone, brand name Subutex) has been generic for a few years and is relatively cheap; some insurance companies have it on their preferred formulary list. For some addiction specialists, plain old buprenorphine is the treatment of choice for opiate maintenance or detox.
In order to be able to prescribe buprenorphine (with or without naloxone), you need a waiver from the Department of Health and Human Services—a system that was established as part of the Drug Addiction Treatment Act of 2000 (DATA2000). To obtain this waiver, you need to go through an 8-hour training, which will enable you to prescribe buprenorphine to up to 30 patients in the first year and as many as 100 patients in the second year. New federal legislation will soon allow for treatment of up to 200 patients after the second year.
Buprenorphine is a Schedule III controlled substance, so it’s less restricted than methadone (which is Schedule II). Patients can get a one-month prescription from a buprenorphine provider with up to 5 refills, although most experts recommend at least monthly visits. One of the reasons buprenorphine is less restricted is because of its safety profile—as an opioid agonist/antagonist, it’s more difficult to overdose on buprenorphine than it is on methadone.
Given that buprenorphine alone is an effective treatment for opioid addiction, why did drug makers create Suboxone, the combination of buprenorphine and naloxone? Wouldn’t naloxone—an opiate blocker used to reverse opioid overdoses—neutralize buprenorphine’s effectiveness, rendering it useless as a treatment? Not if it’s taken sublingually, as directed. When buprenorphine is absorbed through the mouth’s mucosal lining, it works fine— but naloxone is then inactivated. But if you choose to grind the combination pill and dissolve in saline to inject it, the naloxone is very much active, and will prevent you from getting high. So naloxone was added to reduce the potential for abuse by injection.
How to start patients on buprenorphine: Induction
Induction refers to the somewhat complicated process of starting an opioid-dependent patient on buprenorphine (by “buprenorphine” I am referring to any of the preparations, whether mono or combined with naloxone). It can be done in an outpatient setting, and the process usually takes 1–2 days.
I start by emphasizing to patients that they should not use opioids for about 24 hours before presenting for induction—otherwise the first dose will cause an unpleasant withdrawal experience. For those of you who need a review, the early symptoms of opiate withdrawal are anxiety, craving, nausea, aches in the lower back areas and legs, some muscle cramps, and possibly some diarrhea. Later, it gets progressively worse to the point where patients have a runny nose, watery eyes, intestinal cramps, vomiting, muscle twitches, and the famous “cold turkey” goose flesh.
Once they’re in the early stage of withdrawal, start with low doses of buprenorphine, 2–4 mg, and then every hour or two give them additional doses until they’re comfortable. I check on patients every hour or so. We have a waiting room with wi-fi, a DVD player, and magazines, and I tell them, “You’re going to be hanging out for a while. There’s a bathroom very close by.” Medical personnel, myself or my nurse, are checking on them regularly, and they can get someone’s attention right away.
After the second dose, most people are feeling much better physically, so then it’s just a matter of titrating up to where they feel comfortable without “feeling like a zombie”—in other words, too sedated.
Depending on their tolerance, typical doses are between 12 and 16 mg a day. Some people do fine with 10 mg, while some people need more like 20 mg; it just depends on individual tolerance. If they’re feeling sleepy or a little lightheaded, stop dosing wherever they are. I’ve seen a lot of variability in dosing needs. Someone who has been using 8 or 10 Vicodin a day may get by with 8 mg of buprenorphine. But the patient who is injecting a fair amount of heroin multiple times a day may require up to 16 mg or more that first day.
At the end of the first day of induction, I make sure patients have someone who can drive them home. I will usually give them a prescription to pick up a small amount of buprenorphine at the pharmacy. If they absolutely need it, they can take a dose at home. They will rarely actually need it because buprenorphine is long-acting, and once you get the initial dose up during the course of a day, the cumulative effects will get them through at least the next 12 hours or so.
The next morning, the patients come back and we pick up where we left off the day before. I give them the first day’s dose all at once to start with and make sure they can tolerate it, and then if necessary go up from there. It usually takes us two days to find the right dose, but occasionally it takes longer.
The maximum recommended dose of buprenorphine or buprenorphine/ naloxone is 32 mg per day. Due to the agonist/antagonist properties of the drug, doses higher than 32 mg may start to cause some opioid withdrawal symptoms, which is known as the “ceiling effect.” Patients who have been using high doses of opioids, either prescription opioid analgesics or heroin, may need a higher overall opioid dose than can be provided with buprenorphine due to this effect. In that case, these patients would benefit more from methadone maintenance because methadone does not have a ceiling effect. There’s no set upper limit for methadone—the final maintenance dose is based on tolerance and can be affected by other medications that enhance methadone metabolism (such as some of the antiretroviral medications to treat HIV).