Medication alone is not a cure for addiction but when given in combination with counseling/therapy it can significantly increase treatment success rates. Only two medications for treating opioid addiction can be obtained by physician prescription from local pharmacies: buprenorphine and naltrexone. (Methadone is available only in state-licensed clinics.)
Buprenorphine is one of the most effective prescription medications available today for treating opioid addiction. Known under the brand names of Suboxone, Subutex, Zubsolv, and Sublocade, buprenorphine is a uniquely safe and effective medication. It can relieve withdrawal symptoms and eliminate drug cravings without producing an opioid “high” and without depressing breathing to the point of causing a fatal overdose reaction. Buprenorphine makes it easier to stop using opioids and refrain from going back to them. Individuals stabilized on buprenorphine can function normally without having their lives disrupted by drug cravings, obsession, withdrawal symptoms, and financial stressors associated with daily use of heroin or prescription opioids. Studies have shown that buprenorphine works best when given in combination with therapy that teaches relapse prevention and emotional coping skills. Buprenorphine represents the latest advance in medication-assisted treatment (MAT) for opioid addiction and was approved by the FDA for prescription use in October 2002.
How Buprenorphine Works
Buprenorphine is a partial opioid agonist which means that its effects are weaker that full-strength opioid agonists such as oxycodone, heroin, or methadone. As compared to other opioids (full opioid agonists) it does not produce a profound “high” or depress breathing to the point of causing fatal overdose unless it is combined with depressant drugs such as alcohol, Klonipin, Ativan, Xanax, Valium, Ambien, or other sedatives.
Buprenorphine’s opioid effects increase as the dose increases but level off at a certain point so that further dose increases produce no additional effect. This “ceiling effect” lowers the risk of overdose and other adverse effects. Also, because buprenorphine’s effects are long-acting, it is usually taken only once a day. Sublocade, an injectable form of buprenorphine, lasts for up to 30 days after a single subcutaneous (under the skin) injection administered by a physician.
Buprenorphine can be used as a short-term transitional treatment to ease opioid withdrawal in individuals who want to detox and abstain completely from opioids. Sometimes, detox using buprenorphine is followed by induction onto naltrexone, an opioid blocker that can help to prevent relapse.
To an increasing extent these days, buprenorphine is used on an open-ended basis as a maintenance medication together with behavioral therapy or counseling. Contrary to the argument that maintenance treatment with buprenorphine is just substituting one addictive drug for another, studies indicate that buprenorphine is perhaps the singularly most effective medication for treating opioid dependence available today as measured by reduced relapse rates, overdose death rates, and premature dropout from treatment. An added benefit is that buprenorphine often reduces symptoms of depression and anxiety more effectively than conventional medications for these conditions. This is important considering that inadequately treated mood disorders can contribute to opioid relapse.
Phases of Buprenorphine Treatment
- The Induction Phase is the medically managed startup of buprenorphine treatment which generally takes about one week. Patients are advised by the prescribing doctor to delay taking the first dose until about 12 to 24 hours after their last use of opioids when just beginning to feel opioid withdrawal symptoms. If taken sooner, buprenorphine can trigger unpleasant withdrawal symptoms.
- The Stabilization Phase often involves further adjustments in the daily dose of buprenorphine to insure optimal control of drug cravings and withdrawal and that use of other opioids has completely stopped. This phase typically takes about 2-4 weeks.
- The Maintenance Phase occurs when a person is stabilized and doing well on a steady dose of buprenorphine. The length of time that a person stays on buprenorphine is tailored to each individual’s needs and circumstances and may be open ended. Combining buprenorphine treatment with ongoing therapy produces the best outcomes.
Naltrexone (Trexan, ReVia, Vivitrol) is a potent opioid antagonist that blocks the euphoria (“high”) and other physical effects of opioid drugs such as oxycodone and heroin for at least 24 hours after swallowing a 50 mg naltrexone tablet. Naltrexone was developed in the 1970s to prevent relapse to heroin, the most widely used illicit opioid drug at that time.
Naltrexone itself produces no euphoria and is completely non-addictive. Although a highly effective opioid blocker (antagonist), naltrexone’s effectiveness in treating opioid addiction has been limited by at least two important factors: (1) An opioid-free period of at least 1-2 weeks is required before a person dependent on opioids can take a first dose of naltrexone without experiencing a severe opioid withdrawal reaction; and, (2) Because naltrexone (unlike buprenorphine) does not eliminate drug cravings or normalize mood, it is too often discontinued prematurely before a sustained period of abstinence from opioids can be achieved. Despite these limitations, naltrexone can be a very valuable tool for preventing relapse in the early phases of treatment.