Buprenorphine Treatment

What is Buprenorphine?

Buprenorphine (pronounced byoo-pre-NOR-feen) is a  medication that has been used to treat pain for many years and has a well researched safety profile. Researchers in Europe found that many of it's properties made it a useful drug in the treatment of opioid dependency as well as pain, & in October 2002, the Food and Drug Administration (FDA) approved Subutex® (buprenorphine hydrochloride) and Suboxone® tablets (buprenorphine hydrochloride and naloxone hydrochloride) for the treatment of opiate dependence. On October 9, 2009 the FDA approved a generic version of Subutex.

Buprenorphine is derived from thebaine, an alkaloid of the poppy plant Papaver somniferum and is hence it is related to opioid medication but is different from most abused opioids in that it is a "partial opioid agonist".

What this means is that the drug will only partially bind to the opioid receptors in the brain but not produce the same effects that make opioids so physically and psychologically addicting as well as dangerous.

Hence the drug produces much less euphoria (if any), sleepiness or respiratory depression when compared with "full-agonist" opioids like heroin, oxycodone, methadone, hydrocodone etc. The term "full-agonist" refers to the fact that these drugs FULLY bind to the opioid receptors in the brain and produce a markedly stronger effects. 

Once a certain amount of buprenorphine is taken, it will no longer produce any effect with further dosage. It reaches a plateau, and this is called the "ceiling effect". This makes respiratory depression, the major cause of death in opioid abuse, much less likely, as well as decreases it's risk of abuse and other side effects of opiate drugs.

What patients experience are vastly decreased cravings which enable them to focus on treatment and go on with their lives in recovery without the euphoria or high that leads to poor judgment and drug-seeking behavior. 

Understand that buprenorphine is NOT solely for the use of treating opioid dependency. It is a pain medication as well, and is often used in that capacity in patients who do not wish to be placed on other full-agonist opioids. Interestingly enough, it has a long record of safety in veterinary medicine as, when used properly, it does not heavily sedate, disorient, or depress respiration in man's best friend.

ln fact, buprenorphine will actually block the effects of full opioid agonists (heroin, oxycodone, hydrocodone, fentanyl, methadone etc) and can precipitate withdrawal symptoms if administered to an addicted individual while they still have opiates in the bloodstream. Buprenorphine binds to the opiate receptor very tightly and as such will compete for the receptor and win.

It will "knock off" other opioid drugs and occupy that receptor, blocking other opioids from attaching to it. This is termed "precipitated withdrawal", and is very uncomfortable. That's why it is important that you be in withdrawal before your first dose up buprenorphine. We recommend waiting 16 hours between your last opioid use and starting buprenorphine. Patients taking methadone must wait several days. When you call to make your appointment, our staff will tell you how to prepare.

Suboxone, contains both buprenorphine and the opioid antagonist drug called naloxone. An "antagonist" drug will work by binding its target receptor and preventing that receptor from functioning; the very reverse of what an "agonist" will do. Naloxone has been added to Suboxone to guard against intravenous abuse of buprenorphine by individuals physically dependent on opiates. If misused by injection, or snorting, the naloxone will cause immediate withdrawal in opiate dependent people. However when taken sublingually, as indicated, the naloxone isn't absorbed well and is clinically insignificant.

What Kind of Drug Dependency Can Buprenorphine Treat?

Suboxone® is currently FDA approved to treat the dependency of opioid medication. This includes, but isn't limited to: heroin, oxycodone, hydrocodone, morphine, codeine, fentanyl, dihydrocodeine, tramadol . There are early studies demonstrating that buprenorphine may be helpful in treating alcoholism, but these are in the early stages.

What is the Difference Between the Word "Opiate" and "Opioid"?

The term "opiate" was traditionally used to refer to naturally derived products from the opium of the poppy plant (such as morphine and codeine)and "opioid" was used to denote the synthetic and semi-synthetic derivatives (such as methadone or fentanyl).

Currently, the term "opioid" is now used to refer to the entire family of opiates including natural, synthetic and semi-synthetic. Literature currently seems to be leaning toward substituting the word "opioid" in most areas where  the word "opiate" has  previously been used. This is strictly a semantic issue.

Why Isn't This Just Replacing One Addiction For Another?

You are not replacing one addiction for another. You are going to be replacing the tormented life of addiction with medical treatment, accountability, & honesty. They are vastly different conditions and one means of looking at this is to consider the two states, side by side as we have presented them below.

The list below is foreshortened for space, but it is clear that the pain, shame & ruination of addiction is nothing like the partnership of recovery you will form with your medical team, your sponsor and your loved ones:

In My Addiction                                           In Medical Treatment 
                                                                                                                                            Tolerance develops to the drug of abuse          Tolerance is not seen in buprenorphine treatment
You continue to take more just to be “well”      Most begin to take less bupe within months
The lies, deceit & loss of relationships            You will rebuild the trust & love that was so injured
Financial ruin                                                Buprenorphine treatment costs less than $10/day
Ruination of your liver, skin, teeth, etc             Your body will recover and you will feel well
Loss of your reputation                                  You won't be intoxicated or acting like a fool
Your brain’s receptors cannot recover              Brain recovery on buprenorphine is documented
Abstinence based models have <5% success  Bupe based treatment plan w/ up to 80% success

What Can I Expect at Treatment in Your Office?

We understand what you are going through. You may feel like you're the only one doing this and are fearful that people might know you have a problem. Perhaps you are convinced that your spouse, partner, best friends or co-workers don't know, and you cannot take time away to go to treatment.

Although it would be helpful in many instances to be able to go to an in-patient facility for treatment of physical dependency and addiction, it's often not financially, socially, or temporally feasible. Buprenorphine treatment will not require you to take time off from work in most instances.

When you are prepared to begin treatment, you will have an appointment to undergo what is termed "induction". This is when you will take your first dose of buprenorphine. You will take your last dose of opioid drug at approximately 6:00 pm the evening before your appointment. The next day, between 10:00 a.m. and noon, you will be given a buprenorphine dose in the office.

It is crucial that you report whether you took any more of an opioid drug after that 6:00 p.m. dose from the evening before. If you have, and don't report it, you will likely undergo precipitated withdrawal and this is extremely uncomfortable. Often, if you are seen in the office before induction, you will be given a small amount of clonidine and clonazepam to make the evening before induction more tolerable.

After induction, we will assure that you are feeling well and are ready to go home. You will be given a prescription at that point for Suboxone® tablets. We will not let you leave the office until you feel much, much better; you can be confident that you won't be suffering withdrawal if all directions have been followed. You will be seen weekly initially, until you are stabilized & comfortable. This is included in your initial induction fee.

Methadone Patients

Patients who have been taking methadone are a special situation. Methadone has a half-life of up to 36 hours compared with the average half-life of other opioids of 6 hours. A half-life refers to the amount of time it takes for 50% of a drug to leave your system. Approximately 6 half-lives are needed to assure ~98+% of a drug has been metabolized and excreted from your body.

Example: Consider that one has taken 100 mg of an opioid that has a half-life of 6 hours.

Every 6 hours, 50% of the drug will be gone: 
     
    So after 6 hours:        50 mg are left
                12 hours:       25 mg are left 
                18 hours:    ~ 13 mg are left 
                24 hours:    ~   6 mg are left
                30 hours:    ~   3 mg are left
                36 hours:    ~   2 mg are left

Hence, most opioid drugs are out of your system in 6 times 6 hours: 36 hours. Methadone however, with such a long half-life of 36 hours with take 216 hours, or 9 days to be metabolized out of the body.

So if you have taken methadone in the past 5 days before your induction, be certain to tell us and we will make special arrangements for you.

Our Basic Policies:

We will ask you to sign a contract with us wherein you agree to three simple concepts:  

                                                
1. That you will be honest with us
2. That you will show up in a timely fashion for your appointments
3. That you will participate in therapy & 12 step meetings

You will be seen to refill your prescription for Suboxone® at minimum every 2 months and will undergo urinalysis on a random basis. We will ask you to bring your pills to be counted as well.

Understand that you will not be dismissed for "popping positive" if you are honest. If you are indeed positive for an opioid (buprenorphine does not test positive for opioid medications in most urine tests, hence we can tell the difference) drug, or any other drugs of abuse, we need to know as perhaps there is something we can do together to shore up your recovery.

The current cost of care at our office is:
                      
 New Patient  Induction Visit: $395.00
 Follow-Up Visit: $100.00  
 Transferring Patient: Call Us
 

Sources: