Soon after the Drug Abuse Treatment Act of 2000, the FDA approved the medication buprenorphine to treat opiate dependency.
An alternative to methadone maintenance, buprenorphine offered several advantages; first, cooperative, reliable patients could be properly dosed and maintained in doctors’ offices without the inconvenience and stigma of attending methadone clinics; second, because of its chemistry, buprenorphine has little of the pharmacologic effect of opiates—cognitive impairment, gastrointestinal motility disturbance, sexual dysfunction; and third, once titrated properly, the buprenorphine dose needed to stop opiate-craving and prevent withdrawal does not escalate.
For individuals whose lives had deteriorated into a nightmarish cycle of drug-seeking and illegal activities to fund for their habit, buprenorphine presented a medical insurance-covered alternative to methadone, legally obtainable in the offices of certified doctors.
The psychological space and freedom from the all-consuming preoccupation of procuring opiates meant individuals got their lives back.
However, and this is essential to understand from the outset, buprenorphine is most definitely an opiate medication and continues the opiate habit, a point critics of buprenorphine treatment correctly observe.
A Powerful Effect
Even though patients say they feel normal, buprenorphine exerts a powerful pharmacological effect. By analogy to a door studded with keyholes, buprenorphine attaches to the mu subtype of opiate receptors in the brain and body very tightly–think of keys shorn off at the stem of locks—denying access of other opiate molecules that might open the lock.
Thus, abrupt withdrawal or too-rapid tapering of buprenorphine produces all the typical debilitating opiate withdrawal symptoms: nausea, sweating. muscle spasms, flu-like symptoms, restless legs, insomnia, gastrointestinal upset, depression, anxiety and mood lability.
Although it may feel like it to those caught in the vicious cycle of abusecravingwithdrawalrelapse, buprenorphine is most definitely not a wonder drug.
Patients and families should not assume that buprenorphine treatment guarantees an easy taper a few months down the road, or that buprenorphine withdrawal is substantially different from withdrawal from any other opiate.
For reasons not clear, the opiate receptor systems of vulnerable individuals, typically those who have used high doses of opiates for prolonged periods, do not reset themselves to their pre-opiate dependent state.
Would that we could promise people with opiate dependency detoxification and relief from dependency; however, that’s not the way the medicine, or the body, works.
So here the controversy stands.
Should a physician prescribe a medicine that continues the opiate habit in the service of giving his patient a chance to recover his life? Or, should a physician insist on using buprenorphine as an interim solution and taper it as rapidly as possible, even if the withdrawal and likelihood of relapse (with often fatal consequences) threatens his patient’s function?
Skeptical at first because it seemed like substituting one opiate habit for another, it didn’t take long to appreciate how many lives buprenorphine saves.
It had long been appreciated that many, perhaps the majority, of individuals in 12-step programs had dual diagnosis substance use plus psychiatric disorders.
The psychiatric literature is replete with studies of individuals who use alcohol and benzodiazepines to self-medicate panic and posttraumatic stress; and bipolar patients who abuse cocaine and psychostimulants to maintain their ‘highs.”
What became apparent once I treated opiate-dependent teenagers and young adults with buprenorphine was how often they stumbled into opiate dependency in an attempt to self-medicate depression.
Fanned by the introduction of Oxycontin into the medicine chests of mainstream America, Oxycontin was introduced into the blood streams of a depressed teenagers, some of whom had already become discouraged because standard antidepressant medications either didn’t work or made them worse.
“Oxies,” many of them said, were the only drug that ever made them feel good. Because Oxycontin cost so much, many turned to cheap and readily available street heroin. Lives descended into chaos; grades plummeted; trust was shattered as youngsters stole from their parents; capable students dropped out of college too ashamed to ask for tuition refunds; young parents neglected their children.
Meanwhile, the underlying psychiatric disorders were never addressed.
When dual diagnosed youngsters are evaluated by psychiatrists, a frequent pattern emerges: well before the first opiate is ingested, many report early onset of suicidal depression or unrelenting anxiety. “How sick was it,” many a flailing student or college dropout said, “for the nine year me to be thinking about hanging myself or jumping in front of a bus?”
Decades ago, we didn’t appreciate that standard antidepressants make bipolar disorder worse. Now, once these patients are stabilized on Buprenorphine, they are free to participate in therapy that addresses their psychiatric issues, oftentimes, with amazing results.
So: does the doctor prescribe a medication that may be necessary for the indefinite future? Or does he taper and have his patient commit to intensive drug rehabilitation therapy?
I would gladly recommend the latter if it was safe. But a call some years ago from the parents of a buprenorphine-treated young adult who tapered his medication, made a deep impression.
The young man relapsed on heroin laced with fentanyl and would have died had not his parents found him unresponsive on the bedroom floor.
Pills photo available from Shutterstock