After the induction, I will generally see patients weekly, which allows me to make more dosage adjustments as needed. I will increase the dose if there are still cravings and withdrawal symptoms, or reduce it if there are opioid side effects, such as constipation or oversedation.
Life after induction
Maintenance vs. tapering
Once we have arrived at a stable dose of buprenorphine, I begin talking to patients about how long they will need to stay on it. Some people need more time on the medication—many months to years—because of the severity of their addiction and the harsh consequences of relapse. Having such patients on a maintenance dose for many months allows them time to work on the behavioral components that they are learning in therapy or in 12 step programs.
On the other hand, other patients don’t have as severe a problem with opiates, and if they have good social supports, they might be ready for a taper fairly soon after they start. The taper is fairly straightforward. The smallest dosage strength is 2 mg, and people can cut pills or strips in half and taper down in 1-mg increments. I’ll have them decrease the dose anywhere from every few days to every few weeks depending on the time available and the patient’s physical and psychological comfort level. A typical outpatient taper will take around 2 months, and this time can be lengthened depending on the patient’s readiness and starting dose.
In addition to prescribing medication, I make sure that my patients are engaged in some kind of psychosocial intervention. This might be individual counseling, a group program, or involvement with a 12 step self-help group. I want them to be working on relapse prevention skills, coping skills, and refusal skills. And in their home environment, I encourage them to rally as much support as possible from family and friends who are not using drugs.
Psychiatric medications for other symptoms
Antidepressants and other medications for anxiety can be very helpful in supporting recovery, and just about any of the SSRIs and SNRIs are appropriate. Both gabapentin and hydroxyzine are effective anti-anxiety medications that are not controlled substances. For insomnia, there are medications like trazodone.
Benzodiazepines are not ideal for these patients. For one, they can produce a high that may lead to craving and relapse to opiates. In addition, it’s hard to overdose on buprenorphine alone, the combination of buprenorphine and benzodiazepines can more readily lead to overdose. It’s important to let patients know about this risk.
Typical causes of failure of buprenorphine treatment
Lack of support
Lack of good support in the immediate home environment is a big reason why patients may have significant problems remaining abstinent. They need to have family or close non-using friends for encouragement and to help them deal with the emotional and physical ups and downs of being in early recovery.
Using other drugs
Some people don’t want to give up their marijuana or their alcohol, which is another reason for relapse back to opioids. I do random drug testing, and I let people know that the goal is going to be abstinence from all the substances that could cause problems.
Even though maintenance methadone or buprenorphine only target withdrawal from and cravings for opioids as a class, most people will also reduce their intake of other drugs of abuse. This is because the behavioral components of the recovery program are universal, not specific to opioids.
How to choose among the different formulations of buprenorphine
There are several different formulations of buprenorphine available (see our table, “Agents Used in Medication-Assisted Treatment (MAT) for Opioid Addiction, on page 8). Suboxone is the most common combination product and the only one that is FDA approved for induction. It was originally available in sublingual tablets, and now it’s available as strips or films, which are also sublingual. There’s also a different brand name of tablet (Zubsolv), which is a more bioavailable form of buprenorphine. Higher bioavailability means that a larger fraction of the drug is absorbed, which in turn allows for a lower number of milligrams to achieve the same effect. A more recent alternative is Bunavail, a buccal film that is also highly bioavailable and which dissolves on the inside of the cheek as opposed to under the tongue.
The main factor influencing the choice of formulation tends to be what the patient’s insurance policy covers. Some companies simply cover the cheapest product—which is the generic mono product, buprenorphine without naloxone. Other companies will preferentially cover the combination product, typically the Suboxone strips.
In general, I favor the combination product over the mono product, in part because it is more available in pharmacies. Some patients and their families request the combination because they believe having the naloxone adds a measure of safety, although in my experience the scenario the naloxone is meant to prevent (injection abuse) is rarely a concern. The mono product should always be used, however, for pregnant women in order to reduce exposure to medications overall, including naloxone.
Among the combination formulations, Suboxone has been around the longest and is most familiar to patients. The strips tend to be more easily
dissolvable than the former Suboxone tablets, which are no longer marketed. It takes about 5 minutes to dissolve under the tongue, and during that time, the patient shouldn’t talk or swallow (not a fun way to start the day).
The mono buprenorphine tablets take at least 5 minutes to dissolve, and it can take longer if you need two or more tablets. I tell my patients to rinse their mouth out really thoroughly, and then to get it nice and moist before putting the tablet under the tongue, because that will help everything to dissolve.
The Bunavail product is the most recent one to come to market. The claim is that it dissolves the fastest and allows you to talk and eat with the patch on the inside of your cheek.
For each strength of Suboxone film, there is an equivalent strength Zubsolv tablet or Bunavail buccal film, but the equivalent strength does not mean the same number of milligrams of buprenorphine/naloxone due to differences in bioavailability between the different products. The conversion charts tell practitioners what dose of Zubsolv or Bunavail to use for a known dose of Suboxone being taken by your patient. That helps to reduce confusion.
Vivitrol is a long-acting injectable form of naltrexone, which like naloxone is an opiate receptor blocker. Before an injection with Vivitrol, people have to abstain from opioids for at least several days, preferably about one week. You may have to do a detox with methadone or buprenorphine to get patients off their preferred opiates, and then have them stop for a few days. The injections are every 4 weeks, and they can’t be done at home. They are deep gluteal intramuscular injections, and the manufacturer sends kits to the physician’s office. You don’t need any special licensing to administer it; any psychiatrist or primary care practitioner can do it in the office.
Vivitrol is certainly effective to extinguish opioid use, but the potential problem is that people may not show up for subsequent injections. In a psychiatric setting, giving someone who has a dual diagnosis an injection can give both the provider and the patient some peace of mind for a while, so that can be a part of discharge planning.
While the opiate epidemic is serious, we have some excellent tools for helping patients decrease their use of the more dangerous drugs, and in some cases patients can successfully end their opiate use completely. According to the latest follow-up studies, buprenorphine retention rates at 1 year are around 60%–66% (Fiellin et al, N Engl J Med 2006;355:365–374). As far as methadone maintenance, those rates are as high as 80%, according to one recent study (Hser YI et al, Addiction 2014;109(1):79– 87). Medication-assisted treatment for opiate addiction works and should be part of our therapeutic repertoire.