Respect, not coddling, for buprenorphine patients

The opioid scourge continues unabated. People continue to die at a record rate in spite of ever-increasing news coverage of illicit drug use. How can this be?

While friends, family members and others not dependent upon drugs view the flood of information with appropriate alarm, active opioid users do not. They wonder about the newer, stronger street drugs, especially fentanyl, and what it must feel like to find some. Most are sure they will use it wisely. Most do not think they will die. Some do think they might, but are willing to risk it.

How do I know they think this way? I am recovering from opioid addiction (17-plus years), and the thought does not shock me. More importantly, there is a recurrent behavior that provides empirical evidence that impaired thinking pervades the drug-using community.

The promulgation and use of the first aid medication naloxone (Narcan) by healthcare providers, law enforcement and education institutions has offered a window into opioid use and attempts to treat it. Naloxone also is being given to many individuals with opioid addiction who leave various treatment settings for use should they relapse. Consequently, large numbers of patients who relapse are being given the drug, and most are arriving at emergency rooms alive rather than dead. Though this represents progress in initial survival, there is much more to the story.

One would think that these patients would be relieved to have cheated death and would be ready to start a serious attempt at beginning treatment. But this rarely describes the actual scenario. Although naloxone has allowed the patient's breathing to begin again and can help restore a viable blood pressure, the patient quickly awakens in full-blown opioid withdrawal. Under these circumstances, the patient will agree to most any follow-up plan, as long as it starts tomorrow. The immediate need to relieve the worst withdrawal the patient has yet endured becomes paramount in the patient's mind. The addict must use again, as soon as possible. He will leave, against advice if necessary, leaving loved ones and friends bewildered. Chances are, if he doesn't die, he will be back again.

In my capacity as medical director of Phoenix House in Rhode Island, I have seen scores of patients admitted for detoxification and treatment as they continue in their addiction. Many readily admit to having suffered multiple overdoses requiring naloxone reversal within a one-year period. They are aware they are lucky to be alive, and often offer no promises that it will not happen again.

Although the public is baffled by such behavior, we providers cannot be. Respecting the power of a disease that so often brings the patient to the edge of death mandates our attention and resolve to avoid being deceived by our patients.

A boost from medication

It is in the milieu of an opioid treatment center that the patient has the best chance for success. The patient should be offered medication-assisted treatment options. They include: methadone maintenance clinics; naltrexone, orally or in the form of monthly Vivitrol injections; and buprenorphine-assisted recovery. Here I will discuss the latter, as I believe it has been proven to work best for the majority of opioid-dependent patients. This medication has several qualities that make it ideal for those patients who wish to stop using now.

Buprenorphine is a partial agonist (activator) of the mu (opioid) receptors in the brain. It is at these receptor sites where nearly all the damage caused by opioid addiction starts and develops. Here is where tolerance for the opioid occurs. Tolerance is a need to take more of the drug, in use over a shorter period, in order to achieve the same result as when it was first taken. It is also at these receptors where healing can begin quickly by employing the appropriate introduction of buprenorphine into a formally scheduled treatment program.

The patient must be induced (started on the drug) when he/she is in sufficient opioid withdrawal. The state is best determined by a trained provider who uses history, physical examination and urine drug screen results. Although the medication enters the peripheral blood system as soon as it dissolves in the mouth, it will take another 45 minutes for it to cross the blood/brain barrier. The buprenorphine then will quickly attach itself to every mu receptor it can find. Those empty receptors are demanding activation by more opioid in order to stop the tremendous life-controlling dysphoria that has brought the patient near death and now to treatment.

The affinity (adhesiveness or stickiness) of buprenorphine for these mu sites is stronger than that of the common drugs of abuse and will immediately bond with the receptor and not allow other opioids to occupy that space. But instead of fully activating these sites, it will only partially turn them on. This amount of site activation will immediately begin the reversal of the patient's discomfort, but will not activate the receptors enough to reinstate the “high” initially felt by the patient. This limited amount of activation will, however, eliminate the desire to take more of the opioid of choice.

In addition, this small amount of mu activation will provide a slight energetic boost, but is not so energy-producing that the drug develops the tolerance that occurs with all other abusable opioids (including methadone). Practically speaking, this means that the newly induced buprenorphine patient will not feel better by taking more than his particular prescription dosage, but will instead begin to feel dysphoric and nauseated. This absolutely discourages and most often prevents overuse.

After the first few days of dose adjustment, the patient often begins to feel “as well as I did before I started using opioids.” These are frequent comments I hear, as the terrifying craving that had ruled these individuals' lives actually disappears while they are on their regular dose of buprenorphine. They often will share with me that they previously had felt despair over ever finding a way out of their dilemma. The patient now feels that recovery is possible. As powerful and specific as this medication is, the patient is now only beginning the journey to recovery, a journey not thought likely or even possible before.

Continuing treatment

At the very beginning of buprenorphine-assisted recovery, sessions with qualified chemical dependency professionals are necessary to help the patient understand that cross-addiction will jeopardize recovery. The use of other mind-altering drugs poses a major impediment to recovery. Although most opioid addicts will say that neither alcohol, marijuana, benzodiazepines nor cocaine are their “drug of choice,” I insist upon an approach that helps the patient stop even infrequent use of substances.

Sometimes a higher level of care is necessary to help the patient stop other drug use. In cases where the patient refuses to comply, I will suggest transfer to another provider who is less strict about the use of concomitant mind-altering drugs. That threat is often sufficient to ensure compliance. If the patient has a comorbid disorder and had remained opioid-free, then I take responsibility for coordinating care with the other provider of any necessary prescription medications.

The ability to refer a patient to an intensive outpatient program (IOP) or for individual counseling is essential to be able to serve a patient well. Although I ask patients to refrain from beginning an attempt at detoxification from buprenorphine until they have had six straight months of drug-free urines, that does not usually present a problem. By that time, most patients are beginning to thrive. They are getting good jobs, promotions and newer cars, and are regaining family members' trust.

They are at first in no hurry to start dropping their dose. Since I have told them prior to induction that slow reduction of buprenorphine dosage takes years, not months, my patients are in for the long haul. When they begin detox, the early phase will require at least four months to reduce daily dosage by 4 mg (i.e., from 16 mg per day to 12 mg per day). They are reassured that they may slow down the rate or even stop it at any time in the process without penalty.

I am currently waivered to treat 275 opioid-dependent patients. My proudest accomplishment is to be able to report that after a recent review of calendar years 2016 and 2017, 13 patients (all of whom had at least tried heroin) who had never owned a home before were able to purchase one for the first time. All are between 22 and 45 years of age and have been with me for two to five years, and all but three are on a lower dose of buprenorphine than when they began.

This clearly represents more than “not using.” This represents a thriving recovery. This is most rewarding to me as a provider. Helping more patients on this road to buprenorphine-assisted recovery will do much to help reduce the stigma associated with opioid addiction.

Sylvester “Skip” Sviokla, MD, is a graduate of Harvard College and Harvard Medical School. After a successful 25-year emergency medicine practice, he lost his medical license due to opioid addiction. His struggle back to board certification is chronicled in the memoir “From Harvard to Hell … and Back,” published by Central Recovery Press. The author affirms that he has never received compensation from a maker of buprenorphine-containing products and does not own stock in such companies.

Five tips for addiction professionals

1. Doctors who are familiar with treating addiction and who obtain an “X” number in order to prescribe buprenorphine should realize that the patient with an opioid addiction doesn't lose all bad habits in the first month or two he/she is placed on buprenorphine. Normal doctor-patient relations and treatment plans are based on a truthful exchange between the two parties. This is not true with most who have an addiction. In order to help and not enable your patient, assume that an unbelievable story is probably just that: a lie. Always use urine drug screens as reality checks. Your patient's dishonesty will decrease as he/she sees less need for it every day.

2. The near ubiquity of very inexpensive illicit imported fentanyl is causing it to be added to cocaine, marijuana and most other supplies of dealers. Realistic looking “Perc30s” have been found to contain no oxycodone but only illicit fentanyl. The incredibly powerful strength of this drug offers another reason to insist upon no use outside of prescribed buprenorphine.

3. Be certain that the drug screen that is employed in treatment specifically tests for fentanyl.

4. Marijuana use, with or without a medical marijuana card, has no place in the treatment of opioid addiction. All claims to the contrary are baseless.

5. Reduction in criminal penalties for the purchase of illegal buprenorphine on the street, as recommended by some treating entities, is dangerous. It is just as likely to bring the purchaser to a bad end as it is to expose him/her to its benefits. As my experience has shown, buprenorphine-assisted recovery is a process, not just a terrific medication—much as I believe it to be.