Articles -Position Paper On Suboxone Treatment

Position Paper

On

Suboxone Treatment in Treating

Opioid Dependent Patients

By

Don A. Wicklman, D.Min, LMFT, CAP, NCGCII

According to statistics gathered by New Beginnings Detox for the patients seen in the year 2008, over 85% of these patients have been opiate dependent. The remaining 15% of the population were dispersed into various other dependent categories. Of the 85% coming into treatment for opiate dependence, only 5% completed the program with the remaining 95% abandoning the program. There is no evidence available for follow-up studies suggesting whether those abandoning the program remained sober or relapsed.

It has been the position of New Beginnings Detox since its inception that a lifestyle free from any drugs is the end of effective treatment. The abstinence model was and is the model advocated by the policies of New Beginnings Detox. The treatment protocols for opiate dependence were designed to taper the patient off of opiates with Suboxone or Subutex in a minimum amount of time which is in full agreement with current treatment philosophy.

In designing opiate detoxification protocols it was agreed that six weeks of time would be a suitable time period to effect abstinence even when dealing with high doses and lengthy use patterns. It is not clearly evident why six weeks was chosen as a satisfactory detox period. It has been suggested early in New Beginnings history, other medical directors may have suggested this time period as suitable for opiate detox.

New research concerning long term use of opiates however seems to suggest that significant damage done to receptor sites may need a longer time to repair requiring perhaps up to twelve weeks of suboxone detox treatment. It has been determined that twelve weeks is sufficient time for neurological repair allowing the patient to taper off thereby reducing the likelihood to relapse using opiods 

It should be understood that increasing the time needed for opiate detox from six (6) weeks to twelve (12) weeks does not in any way confuse the original intent of New Beginnings Detox which is to provide a drug free lifestyle.

The current change in the length of detox protocol simply reflects the new knowledge available in current research that suggests twelve (12) weeks as the optimum length of detox treatment to insure the highest probability of total abstinence after detox completion.

A recent from the Journal of Addiction Medicine states the following: “Adolescents who experiment with opioids, like their adult counterparts , often do not understand the neurobiologic effects that accompany the transition from episodic opioid use and dependence. All substances of abuse interact with the brain’s dopamine-based reward system. On-going exposure to opioids leads to important changes in the cellular receptors, intracellular function and protein transcription and translation, leading to the clinical phenomena that characterize addiction-physical dependence, cravings, and loss of control over drug use.”

In addition the position taken above the following information is provided. “The adolescent brain is particularly susceptible to the effects of drugs of abuse-leading to the observation that for many, substance abuse is a condition acquired in youth. The brain circuits that are involved with inhibition, emotion and judgment develop during adolescence. The dynamic interaction between developing neurotransmitter systems and drugs of abuse can impair the ability of adolescents to make sound decisions regarding substance use and limits their appreciation of the consequences of their behavior. Impaired decision making can lead to experimentation and subsequent opioid dependence.”   

“A study by Woody and colleagues in JAMA reports the results of an NIH-funded multi site randomized clinical trail of 2 week vs 12 week buprenophine-naloxone treatment of opioid-dependent patients aged 15 to 21 years (mean age, 19 years), in which both groups had their medication tapered at the end of their respective treatments. Nearly half reported injection use, and one-fifth had evidence of hepatitis C infection. The median duration of their opioid use was one year. The primary finding is that the 12-week treatment with buprenophine-naloxone was associated with greater treatment retention and decreased illicit opioid use-but only during the period that medication was provided. The study used multi site design, appropriate eligibility criteria, rigorous methods, and cogent outcomes and provided long-term follow up.”

“While there are still concerns some things seem apparent. “Adolescent opiate dependent patients have greater abstinence while receiving buprenorphone-naloxone. The most important finding in the study by Woody is the rate of relapse in both treatment groups

following the medication taper. Past-week opioid use did not differ by treatment conditions at 12 weeks or 12 months and reported by 38% to 55% to 72% of participants respectively. This finding is of concern given the young age of the participants and their relatively short duration of opiate use. The implication is that adolescent opioid dependents, like their adult counterparts, will likely need to look at long term, rather than short term, opioid agonist treatment. Trials in adults that have compared brief methadone buprenorphine tapers with long-term treatment (6 months to one year) have consistently demonstrated better outcomes with long term treatment. Abstinence rates are uniformly improved with provision of notification over longer periods of time. These trials conducted in adults with longer durations of opioid dependence (eg 5-10 years), were not previously thought  to generalize all adolescents. The unique finding of the sample by Woody et al, that young opioid-dependent patients using for relatively short durations have high rates of relapse when provided with either brief or loner taper using agonist medications, is sobering.”

“The results of this trial should prompt clinicians to use caution when tapering buprenorphine-naloxone  in adolescent patients who receive this medication. Supportive counseling; monitoring for relapse; and, in some cases, naltrexone should be offered following buprenorphine tapers. From a research perspective, additional efforts are needed to provide a stronger evidence from which to make recommendations for adolescents who use opioids. There is limited research on prevention of opioid experimentation and effective strategy to identify experimentation and effective strategy to identify experimentation and intercede to disrupt the transition from opioid use to abuse and dependence. No information is available regarding the efficacy of treatment with medications such as methadone or buprenorphine-naloxone compared with non agonist approaches (eg, naltrexone) or pharmacologic approaches such as short term rehabilitation or partial hospitalization programs.”

“The high rate of relapse seen with both medication protocols in the current trial involving opioid-dependent adolescents, combined with the adverse social, legal and infectious consequences of opioid dependence, combined with the adverse social, legal, and infectious consequences of opioid dependence-and the possibility for overdose with relapse-makes the need for rigorous r4search in this area urgent. These findings are another important reminder that there are no quick fixes for opioid dependence.”

“In yet another study, patients in the 12 week buprenorphine-naloxone group received up to a maximum amount of 24 mg per day and began to taper at week 9 that ended by week 12. Patients in the detox group received up to a maximum amount of 14 mg

buprenorphine per day and ended their taper by day 14. If the patient missed 3 consecutive days of doses medication was stopped; it was not restarted for patients in the detox group. Medication was restarted for patients in the 12 week buprenorphine-naloxone group if they returned within 7 days of their last dose. Patients who restarted were given half the amount of the last dose received and observed for 1.5 hours. If the medication was tolerated, they received a portion or the remainder of the dose. Patients who dropped out for missing medication were encouraged to continue in counseling treatment. Adverse events were assessed  by weekly vital signs, assessments for sedation and withdrawal and questions about additional medications received and adverse effects in weeks 1 through 12; similar assessments were done at 6, 9 and 12. Electrocardiograms and liver enzyme levels were analyzed at baseline and at 4 and  12 weeks.”

“Interestingly, 12 week buprenorphine-naloxone patients had lower portions of opioid-positive urine test results at follow-up, although differences with detox patients were much less than in weeks 1 through 12, possibly because 12 week buprenorphine-naloxone patients tended to be more engaged in longer term treatment.”

Clinical Implications

“Because much opioid addiction treatment has shifted from inpatient to outpatient where buprenorphine-naloxone can be administered, having it available in primary care, family practice and adolescent programs has the potential to expand the treatment options currently available to opioid addicted youth and significantly improve outcomes. Other effective medications, or longer and more intensive psychosocial treatments,, may have similarly positive results. Studies are needed to explore these possibilities and to assess the efficacy and safety of longer term treatment with buprenorphine for young individuals with opioid dependence.”

Sources

Feillin, David, MD. Treatment of Adolescent Opioid Dependence, Journal of American Medical Association, November  5, 2008, Vol 300. p1238-1233.

Woody E. George et al. Extended vs Short-term Buprenorphine-Naloxone for Treatment of Opioid-Addicted Youth, Journal of American Medical Association, November 5, 2008, Vol 300, No 17, p1334-1335.

Extended Suboxone Treatment Substantially Improves Outcomes for Opioid-Addicted Young Adults. National Institute of Health, http://www.nih.gov/gov/health/nov2008

Retreived December 23, 2008