Revisiting Suboxone: Maintenance versus Total Detoxification

Posted on Wednesday, March the 17th at 2:37pm

Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

In my research and speaking with colleagues, I’ve come across differing opinions on whether patients should be maintained on Suboxone (Buprenorphine) or go through a total detoxification for opiate addiction.  A similar debate has been going on for decades about another medication used for opiate addiction treatment—methadone.  I would like to propose a third option: using the medications as a transitional treatment intervention with eventual discontinuation.

Unlike methadone, physicians are more likely to prescribe Suboxone in their offices for people who are dependent or addicted to opiates such as opiate pain medication, heroin, or methadone.  Buprenorphine (the active treatment medication in Suboxone) is a more convenient maintenance medication for opiate addiction because it does not require daily or weekly visits to a clinic.  Buprenorphine blocks the effects of other opiates, reduces or eliminates cravings and prevents withdrawal symptoms such as pain and nausea.

Subutex and Suboxone are the brand names that Buprenorphine is being marketed under for the treatment of opiate dependence.  Both medications contain the active ingredient Buprenorphine Hydrochloride, which works to reduce the symptoms of opiate dependence.  Subutex contains only Buprenorphine Hydrochloride which was the product initially developed.

The second medication, Suboxone contains an additional ingredient called Naloxone to guard against misuse or abuse. Subutex is usually given during the first few days of treatment, while Suboxone is used during the maintenance phase of treatment. Both medications come in 2 mg and 8 mg strengths as sublingual (placed under the tongue to dissolve) tablets.

It is important to understand why Suboxone is such a good treatment intervention for opiate addiction.  When opioids attach to the mu receptors, dopamine is released, causing pleasurable feelings to be produced.  As opioids leave the receptors, pleasurable feelings fade and withdrawal symptoms (and possibly cravings) begin.  Opioids continue leaving the mu receptors until the person is in a mild-to-moderate state of withdrawal.  At this point, Suboxone therapy can begin.

The primary active ingredient in Suboxone—buprenorphine—attaches to the empty opioid receptors, suppressing withdrawal symptoms and reducing cravings.  As a partial opioid agonist, Suboxone works by controlling withdrawal symptoms and cravings and produces a limited euphoria or “high.”  Buprenorphine attaches firmly to the receptors.  At adequate maintenance doses, Buprenorphine fills most receptors and blocks other opioids from attaching. Buprenorphine has a long duration of action, so its effects do not wear off quickly.

While Subutex (Buprenorphine sublingual tablets) is intended to be given as treatment begins and under close medical supervision, only Suboxone (Buprenorphine plus Naloxone) is formulated to be taken at home.  Misuse or illegal transfer of Subutex or Suboxone could place office-based treatment for opioid dependence at risk.  Adding Naloxone was an important step in creating an FDA-approved treatment option that could be given in the privacy of a doctor's office and taken in the privacy of the patients own home (www.suboxone.com).

One significant drawback with this medication for opiate addiction treatment is that only qualified doctors with the necessary DEA (Drug Enforcement Agency) identification number are allowed to offer in-office treatment and provide prescriptions for ongoing opiate addiction treatment maintenance.  Up until very recently, prescribers were limited to a 30 patient ceiling.

Fortunately, the Office of National Drug Control Policy Reauthorization Act of 2006 (ONDCPRA) modified the restriction on the number of patients a physician authorized under the Drug Addiction Treatment Act of 2000 (DATA 2000) may treat subject to the following conditions:

• Physicians must currently be authorized under DATA 2000.
• Physicians must have submitted the notification for initial authorization at least one year ago.
• Physicians must submit a second notification that conveys the need and intent to treat up to 100 patients and certifies their necessary qualifying criteria and their capacity to refer patients for appropriate counseling and otherappropriate ancillary services.
• Patients can be maintained on buprenorphine or go through detoxification.

Because Suboxone is a partial opiate agonist, some dependence can result from long-term use. We are now beginning to see people abusing Suboxone. Often this is because they are only receiving the medication without counseling or any other therapeutic treatment.  Unfortunately many people are not offered programs that are specifically designed to help people transition from Suboxone to abstinence-based sobriety. 

Medication can only help with the physical part of opioid dependence.  It takes more than medication for patients to understand their triggers or how to cope with high-risk situations. Regular involvement in some form of counseling during Suboxone treatment is strongly encouraged.  Counseling helps patients develop coping skills that can help them avoid relapse and has been shown to significantly improve the likelihood of long-term treatment success.

I personally believe that in most cases Suboxone should be used as a transitional medication and eventually be eliminated.  For some people this can be accomplished in a few weeks, but in others several months to a year may be needed.  But because the drug is an opiate agonist, the final Suboxone taper must occur slowly over the course of several weeks.  If the drug is stopped abruptly, withdrawal symptoms similar to what was experienced at the time of induction can occur.  During this phase there needs to be a slow decrease of the dose, being careful to do so in a manner that produces the fewest withdrawal symptoms or opiate cravings with the eventual goal of stopping Suboxone treatment altogether.

Buprenorphine is also being used very effectively by some pain management physicians for people living with chronic pain.  It is important to remember that medication is only one modality for effective chronic pain management.  For it to be effective, non-medication based treatment interventions must be developed, as well as learning to treat the psychological/ emotional components of chronic pain.  A multidisciplinary team approach always gives the best treatment outcomes.

For someone with chronic pain who has developed an addictive disorder this medication may be the best transitional intervention possible, along with concurrent addiction treatment modalities.  In addition, helping people differentiate between the physiological and psychological/emotional components of their pain and then developing cognitive behavioral approaches will help them manage these components more effectively.