Buprenorphine: When to stop treatment

Patients who are managing an opioid addiction in part by using a buprenorphine/naloxone formulation (such as the brand-name drugs Suboxone, Zubsolv and Bunavail), along with therapy to deal with psychosocial barriers to recovery, will see one of two possible trajectories in their treatment. In one scenario, the goal is to determine the lowest effective dose of buprenorphine and to continue that daily dose as maintenance treatment, so as to eliminate a number of physical withdrawal symptoms. Buprenorphine's ability to prevent withdrawal and to knock out cravings without producing a high allows the opioid addict to return to a normal life.

A second approach to the use of buprenorphine is as a means of facilitating elimination of narcotic dependency by tapering the dosage gradually, allowing the body to adapt to lower and lower drug levels in the blood. This brings us to a major question at hand in the treatment community: How can we tell that the time has come for a patient to come off buprenorphine?

Available research supports the finding that buprenorphine maintenance supports long periods of abstinence and functionality. Longer time on maintenance may improve success rates of eventually tapering off. But there is not enough clinical evidence to state definitively how much maintenance is enough to ensure success. There is no clear-cut answer, but experience suggests some helpful guidelines.

Account for history

First, assess where the patient has come from. How long has the patient been a user, and how severely? How many times has he/she tried to quit, by whatever means, and then relapsed? What does the patient expect from treatment?

A patient who has injected heroin for 30 years, is currently using large amounts of the drug daily along with other substances, and is mandated to treatment by the justice system is likely to require a longer duration of treatment than someone who has been using prescription opioids for six months following surgery and is seeking to get clean prior to starting a family.

Most people, thinking about continuing to do anything perceived as undesirable, such as relying on medication, will state that they don’t want to be doing it “for the rest of my life.” Yet many patients in a treatment program, even those who are doing well, are hesitant to reduce their buprenorphine regimen. It takes time to establish a self-confidence to move from maintenance to weaning off.

Level of responsibility

Second, is the patient prepared to accept responsibility for recovery? Does he believe the reasons for having become an addict all reside outside himself?

Many people seeking buprenorphine treatment cite the prescribing of narcotic pain medications as the beginning of their addiction. Does the patient believe in such a case that the doctor is somehow at fault? An emphasis on external realities that the patient may hold responsible for the situation serves only to distract the patient from committing to not using drugs. For why would the patient put out the effort if the fault lay elsewhere?

Ability to cope

Third, evaluate the patient's judgment. Is it reasonable for the patient to move on in recovery at this time? If she were weaned off buprenorphine completely, how likely would she be able to avoid those situations that tend to undermine one's conviction to stay clean? What is her plan to deal with life stressors that might tempt her to resume using?

Belief in self

Fourth, does the patient believe he can succeed? Wishing and wanting do not take the place of actually doing. But the patient who does come to a pause in progress has to be reminded that he has a serious disease, and can’t blame himself for having it. The patient also must accept the burden of dealing with it healthfully. At any time during tapering, it might come to a point that further weaning is causing the body to reveal a lack of sufficient buprenorphine. It might be necessary to hold at a new maintenance dose, without giving up the final goal.

Health-promoting behaviors

There exists a general consensus among drug treatment practitioners and recovering addicts as to needed behaviors to maintain sobriety:

• Abstinence. It seems unnecessary to state that in order to remain sober, you have to refrain from using. By definition, the addict is not able to use in moderation.

• Avoidance of users. When a person’s immune system is impaired, he/she is advised to avoid contact with others who are coughing and sneezing to avoid the spread of germs. Similarly, an addict in recovery is advised to avoid others who are using, to avoid the urge to use.

• Shutting off access. You can’t use what you don’t have.

• Avoidance of triggers. Recovery 101 teaches to avoid people, places, and things that stimulate one's return to using.

Pain and possible mental health problems, when applicable, also must be taken into consideration. Frequently, those addicted to opioids initially started to use either prescribed or non-prescribed drugs to gain relief from pain or mental health issues. While taking buprenorphine, the patient gains some relief from pain, depression, anxiety and other emotional fluctuations. As the dose is lowered or stopped, one risks a recurrence of these issues. It is crucial that the patient attend to these issues prior to leaving buprenorphine maintenance.

Many practitioners and recovering addicts recommend a positive, active, continuing support system. Some recommend remaining in treatment. Others push for 12-Step support, and/or a sponsor. Many also recommend a strong spiritual base. The patient need not be a member and regular attendee of a religious organization, but will derive great benefit from belief in oneself, faith in a source of guidance superior to oneself, hope for the future, meaningfulness to life, purposefulness of existence, and trust in others.

Finally, the patient need not condemn himself. This is a condition that the patient didn’t ask for and couldn't prevent. Addiction is a chronic illness, but overcoming it is possible. Until that elusive time to wean off comes, the patient should take the medication, like anyone with a chronic disease. With help, determination and proper preparation, the patient may be able to shed the need for all drugs, including buprenorphine.

Roland B. Vendeland, MEd, MA, LPC, a psychotherapist, is a counselor at the outpatient Suboxone maintenance clinic of Hutton Healthcare Services in Bridgeville, Pa. Ronald Rager, MD, MPH, is a private-practice physician in Pittsburgh who treats 100 patients with buprenorphine/naloxone.