According to a recent study by Drug and Alcohol Dependence, many patients who have been prescribed Suboxone and Subutex for their opioid use disorder were not able to stop taking the medication. Both medications contain the active ingredient buprenorphine which works as a partial opioid agonist meaning that the medication produces opioid effects and side effects but does not reproduce the extremes of a heroin addiction. This helps prevent withdrawal symptoms caused by an opioid addiction.
The goal for most patients wanting an opiate detox is to gradually taper off the medication but many find it difficult to do so. Statistics from a trial conducted on the efficacy of extended vs short term buprenorphine treatment for opiate addiction published in the Journal of the American Medical Association found that longer term usage was more effective.1 The findings showed that 80% of young people addicted to morphine started using morphine again if buprenorphine was only used for a short period of time before tapering. In comparison, 70% of those that took the medication for a longer time were able to continue abstaining from morphine during long-term treatment.
Researchers conducted a retrospective cohort study of 1,308 adults receiving buprenorphine. During a median follow-up of 316 days, 48 patients tapered off the medication, for an estimated proportion of 15% (95% CI, 10–21) of all patients. Only 22 of these tapers were medically supervised, and after a median follow-up of 490 days, 27% had resumed buprenorphine treatment.2
Tapering off any chronic medication is a difficult prospect for any disease and in many cases will require significant lifestyle changes (as is the case for diabetes and blood pressure medications). When the withdrawal symptoms of an opiate addiction are factored in, it is unsurprising that so few patients are able to taper off and remain off medications. As can be seen from the study, the chronic relapsing nature of the opioid epidemic means that medical professionals need to help people get into, and stay in care. Many insurance companies cap the duration for which people can be on buprenorphine which why it is essential that health care parity is addressed in the opioid epidemic. Many people require indefinite maintenance and need to have access to lifesaving care.
A long-term opiate addiction leads to an increase in the number of receptors in the brain, known as upregulation. More receptors develop as the amount of opiates used increases and consequently higher doses of opioids are needed to occupy the receptors. In this way tolerance for opioids increases and instigates a vicious cycle of use and increased tolerance (the more opioids are used, the more they are needed). Long-term opioid usage creates an overabundance of receptors that make abstinence almost impossible. Opiate replacement therapy is therefore a necessary medical intervention.
For Suboxone patients only fills the receptors partially, allowing people to avoid withdrawal. When a patient begins their Suboxone regimen they will generally be given the lowest dose possible that helps them to avoid withdrawal. When the patient is ready to taper, they will reduce their dose. It is physically very difficult to go from two milligrams of Suboxone down to zero as PET scans show that even this low dose is continuing to occupy receptors. It is this physical reason that tapering the last two milligrams is so difficult to achieve and needs to be done slowly to make the transition successful.
Many doctors lack the information required to effectively counsel their patients in the process of tapering. The lack of training and attention given to addiction treatment including opiate and particularly heroin addiction is worryingly brief. Currently, doctors in primary care environments including doctor’s rooms and health clinics have little to no training on addiction (66% of US medical schools require an hour or less of addiction treatment training). They are also often under-equipped to refer people with opiate addictions to a qualified addiction specialist who would be able to assist the patient.
However, there are encouraging signs. In 2016 the Obama administration made it easier for people with a heroin addiction (or an addiction to other opioids) to access treatment. Licensed doctors are now able to treat up to 275 patients per year (almost triple the previous limit of 100) meaning that as many as 70 000 more people will have access to Suboxone as a result.3
There are many articles and ‘how-to’ articles available online promising to help people taper, and eventually stop using Suboxone and Subutex. But the statistics show that when individuals try to reduce their medication by themselves they are often unsuccessful and the outcomes range from having to re-up their buprenorphine doses to relapsing back into addiction.
Suboxone (or Subutex) for opiate detox treatment is often continued indefinitely which leads to many people who take the medication feel that they have traded one addiction for another. They may be putting themselves under pressure to stop, or receiving encouragement from family or friends to discontinue buprenorphine treatment in an effort to be completely free of their opiate addiction. This pressure is dangerous and risks the person relapsing back into true addiction.
The most successful outcomes for stopping buprenorphine medication includes firstly, a long-term outlook on reducing dosages and eventually tapering to zero. And secondly, an integrated approach with a qualified health professional to monitor and assist with the process rather than the person trying to do it alone.
Dr. Vikram Tarugu, M.D, is the CEO of Detox of South Florida, Inc and medical professional focused on addiction. A veteran in the medical field with over 25 years of professional experience. He is a consultant for many South Florida Rehab centers. Patients travel from allover the US to seek his help with addiction and Hepatitis C treatment.
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