Understanding Opioid Dependence
More and more, opioid dependence is being accepted as a chronic disease, much like high blood pressure or diabetes.
Yet unlike these other diseases, opioid dependence carries a very powerful stigma. (To illustrate: Imagine that you are interviewing for a new job. Would you think twice before asking whether the company’s health plan covers costs related to your insulin dependence? Would you also not hesitate to ask about coverage of costs related to your opioid dependence?
This stigma is rooted in the centuries-old belief that opioid dependence is a moral failure. It was only within the last 20 years that researchers began to realize opioid dependence was a medical condition caused by changes in the brain—changes that didn’t go away, sometimes for months, after patients stopped using opioids.
Today, opioid dependence in the United States is growing at unprecedented rates. Sadly, fear of the stigma associated with treatment keeps many people from seeking help. Removing the stigma of opioid dependence is critical to helping patients receive proper care. A key part of achieving this goal is wider recognition that opioid dependence is a medical—not a moral—issue.
The information here is offered to help promote better understanding of opioid dependence as a medical condition by exploring the prevalence, biological origins, impact on behavior, and symptoms of this disease.
Office Based Detox Program (SUBOXONE)
UBOXONE is the first opioid medication approved under DATA 2000 for the treatment of opioid dependence in an office-based setting. SUBOXONE also can be dispensed for take-home use, just as any other medicine for other medical conditions. The primary active ingredient in SUBOXONE is buprenorphine. Because buprenorphine is a partial opioid agonist, its opioid effects are limited compared with those produced by full opioid agonists, such as oxycodone or heroin. SUBOXONE also contains naloxone, an opioid antagonist.The naloxone in SUBOXONE is there to discourage people from dissolving the tablet and injecting it. When SUBOXONE is placed under the tongue, as directed, very little naloxone reaches the bloodstream, so what the patient feels are the effects of the buprenorphine. However, if naloxone is injected, it can cause that person to quickly go into withdrawal.
SUBOXONE at the appropriate dose may be used to:
Suppress symptoms of opioid withdrawal
Decrease cravings for opioids
Reduce illicit opioid use
Block the effects of other opioids
Help patients stay in treatment
SUBOXONE treatment can be broken down into 5 phases: Intake Induction Stabilization Maintenance Medically Supervised Withdrawal
The following are general descriptions of each of these phases; the details of your treatment will depend on the procedures adopted by your doctor’s office.
Before you begin treatment, the doctor or nurse will ask you questions about your medical health history, your mental health history, and your substance use history, including your current opioid use. There are no wrong answers to these questions—the goal is to be sure that your doctor has accurate information so she or he can create a treatment plan that meets your needs. All the information you give will be held strictly confidential.
During this visit, you and your doctor will go over the pros and cons of SUBOXONE treatment (if you haven’t already). Your treatment expectations, as well as your doctor’s expectations of you, will be discussed.
The goal of induction is to switch you from your current opioid (heroin, methadone or a prescription painkiller) on to SUBOXONE. You MUST arrive for your induction already experiencing mild-to-moderate opioid withdrawal symptoms. This point cannot be emphasized enough. If you take SUBOXONE before you are in withdrawal, the medication will make you feel worse because it can cause withdrawal symptoms. Your doctor or nurse will assess your withdrawal symptoms and give you your first SUBOXONE dose in the office. Patients can begin to feel some relief within 20 minutes, although the full effects take about an hour, at which point your symptoms will be reassessed. Your doctor may suggest that you pass the time in the waiting area or by taking a short walk and returning to the office at a specific time. Depending on the extent to which the first SUBOXONE dose suppressed your symptoms, your doctor may decide to give you a second dose.
When you are ready to leave the office after your first induction visit:
Your doctor will make arrangements for you to have SUBOXONE to take home. Typically, your doctor will give you a prescription for the amount of SUBOXONE that you will need until your next appointment, along with any special instructions related to your care
Your doctor may also prescribe other medications to help control withdrawal symptoms
During induction, daily appointments are not uncommon. This allows your doctor to adjust for your withdrawal symptoms and cravings. Induction can last anywhere from 2 to 7 days. Patients whose SUBOXONE dose may be too low often use other drugs to try to suppress the withdrawal symptoms and cravings; doctors look for this when evaluating whether a patient is at the right dose. Intake and induction may both occur at the first visit, depending on your needs and your doctor’s procedures.
During stabilization, your SUBOXONE dose is “fine tuned” about once a week, as needed. The goal is to find a dose where your withdrawal symptoms and cravings are suppressed, and you experience minimal to no side effects. You and your doctor will discuss your treatment options going forward, specifically, maintenance versus medically supervised withdrawal.
Once your dose is stabilized, the maintenance phase of treatment begins. During maintenance, your treatment compliance and progress will continue to be monitored. Participation in some form of behavioral counseling is strongly recommended to maximize the likelihood of your treatment success. You and your doctor will discuss counseling options that meet your needs. Your doctor may request urine samples from time to time. Some doctors find urine testing a helpful part of treatment because by verifying the absence of opioids in your system they can evaluate the effectiveness of your SUBOXONE dose. Talk with your doctor if you have questions about the role of urine testing in treatment. During your ongoing maintenance treatment, your doctor will want to know if you experience any cravings. If you do, your dose may need to be adjusted. Appointments are usually scheduled on a weekly basis, however, if treatment progress is good and goals are met, monthly visits may eventually be considered sufficient. The maintenance phase can last anywhere from weeks to years—depending on what you, your doctor, and, possibly, your therapist or counselor determine is best for your individual needs.
Medically Supervised Withdrawal
Length of therapy is up to your doctor, you, and sometimes your therapist or counselor. In this phase of medically supervised withdrawal, your doctor will slowly taper your SUBOXONE dose, taking care to see that you experience minimal withdrawal symptoms or cravings. Your dose can always be changed if you experience uncomfortable symptoms or cravings at the reduced dose
How to Take SUBOXONE
Always take your SUBOXONE exactly as prescribed by your doctor
Before taking SUBOXONE, it’s a good idea to drink some water to moisten your mouth. This helps the SUBOXONE tablets dissolve more easily
If your dose is 1 SUBOXONE tablet/film, place it under your tongue, lean your head slightly forward, and let the tablet dissolve completely. SUBOXONE is absorbed into the bloodstream through the veins under the tongue
If your dose is 2 tablets/films, place both of them under your tongue, 1 on the left side and 1 on the right side (you can use a mirror to make sure the tablets are in the proper places). Lean your head slightly forward, and let the tablets dissolve completely
If you have more than 2 tablets to take, put the next tablet(s) under your tongue after the first tablets have dissolved
SUBOXONE takes a short time (about 5 to 10 minutes, but sometimes more) to dissolve completely. Don’t chew or swallow the tablets/films, because less SUBOXONE will be absorbed into your bloodstream, it will not work as well, and your withdrawal symptoms could worsen
Talking while the tablets are dissolving can interfere with how well SUBOXONE is absorbed
You may want to do something that doesn’t require talking, such as reading or watching television, while waiting for the tablets/films to dissolve
Let family and friends know that you won’t be able to answer them or talk on the phone during this time
Important SUBOXONE Safety Information
Injecting SUBOXONE is dangerous and can cause severe withdrawal symptoms, painful or collapsed veins, blood clots, and increased risk of infection
Your friends and family should be advised that an ambulance should be called right away in the event that you become extremely sleepy, the pupils of your eyes become like pinpoints, you feel faint or dizzy, or your breathing becomes much slower than normal
It is important that you take your SUBOXONE or SUBUTEX® (buprenorphine HCl sublingual tablets) with your other medications exactly as directed by your physician. Abuse or misuse of your medications while on SUBOXONE or SUBUTEX can cause death.
A number of deaths have occurred when dependent people have injected buprenorphine, usually together with benzodiazepines. While you are being treated with SUBOXONE or SUBUTEX, do not use benzodiazepines, tranquilizers, or sedatives unless they have been prescribed by your doctor. Do not drink alcohol while taking SUBOXONE or SUBUTEX.
Frequently Asked Questions
Does SUBOXONE just substitute one dependence for another?
All opioids can cause physical dependence. SUBOXONE belongs to a class of opioids called “partial opioid agonists.” As a partial agonist, buprenorphine appears to produce less physical dependence, limited euphoria, and less potential for abuse compared with a full agonist, eg, heroin, oxycodone, and hydrocodone. SUBOXONE has potential for abuse and produces dependence of the opioid type with a milder withdrawal syndrome than full agonists. When patients are ready to stop taking SUBOXONE, the dose is slowly and gradually tapered. The withdrawal symptoms of SUBOXONE are milder than those seen with a full opioid agonist and can be managed with your doctor’s supervision
Can I switch from methadone to SUBOXONE?
It is possible to switch to SUBOXONE from methadone treatment, but because everyone’s situation is different, switching should first be discussed with your doctor.
Why do I need to be in withdrawal when I start SUBOXONE?
It is important to be in mild-to-moderate withdrawal when you take your first dose of SUBOXONE. If you have high levels of another opioid in your system, SUBOXONE will compete with the other opioid molecules and knock them off the receptors. SUBOXONE then replaces those opioid molecules on the receptors, but because SUBOXONE has less opioid effects than full opioid agonists, you may go into withdrawal and feel sick. This is called precipitated withdrawal. If you are already in the first stages of withdrawal when you take your first dose, SUBOXONE will make you feel better, not worse. Once your doctor has assessed your withdrawal symptoms and decided that you are ready to start SUBOXONE, you will begin Induction.
How long will I stay on SUBOXONE?
The length of your SUBOXONE treatment depends on what your doctor, you, and, possibly, your counselor or therapist decide is best for your needs. Although short-term treatment may be an effective option for some, for others it may not allow enough time to address the psychological and behavioral aspects of their condition. The chance of relapsing can be higher with short-term treatment because patients have less time to learn the skills needed to maintain an opioid-free lifestyle. In general, suppressing cravings with SUBOXONE (for as long as necessary), together with counseling, offers the best likelihood for treatment success. Discontinuing SUBOXONE abruptly can cause withdrawal symptoms, so when you are ready, your doctor will gradually taper your SUBOXONE dose. You should be aware of signs of relapse or withdrawal symptoms. Discard any leftover pills to ensure that they aren’t used by anyone else.
Important directions about SUBOXONE use
Intravenous misuse of buprenorphine, usually in combination with benzodiazepines or other CNS depressants, has been associated with significant respiratory depression and death.
SUBOXONE combined with medications/drugs
It can be dangerous to mix SUBOXONE with drugs like benzodiazepines, alcohol, sleeping pills and other tranquilizers, certain antidepressants, or other opioid medications, especially when not under the care of a doctor or in doses different from those prescribed by your doctor. Mixing these drugs can lead to drowsiness, sedation, unconsciousness, and death, especially if injected. It is important to let your doctor know about all medications and substances you are taking. Your doctor can provide guidance if any of these medications are prescribed for the treatment of other medical conditions you may have.
Potential for dependence
SUBOXONE and SUBUTEX® CIII (buprenorphine HCl sublingual tablets) have potential for abuse and produce dependence of the opioid type with a milder withdrawal syndrome than that of full agonists.
There are no adequate and well-controlled studies of SUBOXONE (a Category C medication) in pregnancy. SUBOXONE should not be taken during pregnancy unless your doctor determines that the potential benefit to you justifies the potential risk to your unborn child. Contraception should be used while taking SUBOXONE. If you are considering becoming pregnant or do become pregnant while taking SUBOXONE, consult your doctor immediately. Many women also have changes in menstruation when they use opioids. This may continue while you are taking SUBOXONE. It is important to remember that you can still become pregnant even with irregular periods.