Buprenorphine is the first major medication approved for the treatment of opioid addiction in almost twenty years. In terms of efficacy and convenience it has several major advantages over the existing medications; methadone and naltrexone. The NIDA Research Report on Heroin Abuse and Addiction describes the clinical benefits as follows: “Buprenorphine is a particularly attractive treatment for heroin addiction because, compared with other medications, such as methadone, it causes weaker opiate effects and is less likely to cause overdose problems. Buprenorphine also produces a lower level of physical dependence, so patients who discontinue the medication generally have fewer withdrawal symptoms than do those who stop taking methadone. Because of these advantages, buprenorphine may be appropriate for use in a wider variety of treatment settings than the currently available medications”.
Unlike the treatment of other addictive substances like cocaine, alcohol, marijuana, nicotine etc. opioid treatment is heavily dominated by dependence producing medications. The two established drugs, methadone and LAMM and now buprenorphine have an addiction potential and are either restricted to clinics or a limit set on how many patients can be treated by an individual physician. Naltrexone, the only non-dependence producing medication developed by the federal government is virtually not used on the grounds of poor compliance. Indeed, no other treatment is placed under such restrictions as the treatment of opioid addictions. This has created a unique set of problems and has needlessly added to the existing stigma surrounding the disease. This forced opioid addiction outside mainstream medical treatment.
The most enduring ‘cures’ of the past for alcoholism and drug addictions were predominately dependence-producing substances. The very nature of addiction gave dependence-producing drugs an illusion of satiating the craving for the offending drug. In the absence of the understanding of the neurobiology of addictions and a limited understanding of pharmacology, hallucinogens and other addictive drugs created an illusion of cure. Therefore, it was not surprising that beer was a good treatment for addiction to distilled spirits like gin, rum and whisky. Preparations containing opium or morphine compounded in alcohol were extensively used to treat alcoholism and patients seemed to love the remedies. Newly discovered drugs like cocaine and heroin appeared to be highly effective and innocuous. Heroin (the hero drug in German) was the ‘perfect’ remedy to treat addiction to morphine. Hallucinogenic drugs like LSD appeared to completely curb the cravings for alcohol and were boldly proclaimed by highly esteemed scientists as a treatment for the most intractable cravings.
The discovery of new classes of drugs spawned newer theories and hypothesis. The discovery of benzodiazepines led to the ‘GABA deficiency’ theory of alcoholism and The Federal and State agencies are spending considerable funds to promote buprenorphine and getting physicians to complete the pre-requisites to prescribe the medication. The response has not been as strong but is gaining momentum. In certain parts of the country like the Northeast, physicians have quickly reached the maximum limit of 30 patients and often opioid addicts have difficulty finding a physician.
Amid the excitement and euphoria on the availability of a treatment modality we need to be aware of a disturbing trend which could besmirch this medication and send it the way so many other medications of the past. The annals of our field are littered with sure-fire cures that ended doing more harm than good. To cite just a few examples, benzodiazepines and LSD to treat alcoholism; Laudanum which contained high concentrations of morphine to treat alcoholism; heroin to treat morphine addiction, benzodiazepines to treat alcoholism and the list goes on. The indiscriminate use of highly addicting drugs resulted not only in the rejection of medications to treat addictions and alcoholism but an enduring distrust of science and the medical community which still exists today.
Buprenorphine is first drug in the treatment of any addictive disorder to exceed sales of $1 billion. With the more widespread use of this medication, we have seen a growing problem with diversion and abuse. The company that makes the drug has now come up with the ‘film’ and plan to discontinue the sublingual tablet. Buprenorphine is now available as a generic and this could potentially lead to increased abuse and diversion. The myths about SUBOXONE continue to hold fast. Here are just a few of them:
- The ‘naltrexone’ (the actual drug is naloxone) prevents the medication from being abused;
- Buprenorphine has a ‘ceiling’ effect on the ‘high’ and therefore is non-addicting;
- Buprenorphine can be stopped immediately;
- Many physicians and patients do not know why SUBOXONE contains naloxone;
The warning signs of abuse should be carefully looked and these include:
- Patients wanting only a script for the buprenorphine and refusing counseling
- Insisting that they need the maximum dose to feel well
- Bartering/selling/giving the buprenorphine to other addicts
- Testing positive for opioids or refusing urine screens
- Patients ‘losing’ the scripts and asking for a new script
- Using more than the prescribed dose
- Using buprenorphine intermittently to sustain heroin use
- Resisting attempts to taper down the dose and getting off the medication
- Doctor shopping
These early warning signs have made some physicians take their names off the buprenorphine locator and others not wanting to be on the locator. It may potentially slow down the efforts to get more physicians trained on the use of buprenorphine.
If we in the treatment community are not vigilant, there is a very real danger that more restrictions may be imposed by authorities like the International Narcotics Control Board on the use of buprenorphine and deprive us of an effective tool in the treatment of heroin addiction. Let us learn from the past mistakes and make sure that this valuable medication does not become a street drug and add to the stigma associated with addiction.
- TIP 40. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.
- NIDA Research Report Series: Heroin Abuse and Addiction.
Percy Menzies, M. Pharm. is the president of Assisted Recovery Centers of America (www.arcamidwest.com), a St. Louis-based treatment center for alcohol and drug use disorders. He can be reached at: firstname.lastname@example.org.