Buprenorphine (Suboxone) for the management of opioid withdrawal

[Justin]

Note: buprenorphine = Suboxone®, Subutex®, Buprenex®


Buprenorphine for the management of opioid withdrawal
Cochrane Database Syst Rev. 2009; (3):CD002025 (ISSN: 1469-493X)

Gowing L; Ali R; White JM. Discipline of Pharmacology, University of Adelaide, Frome Road, Adelaide, South Australia, Australia, 5005.

BACKGROUND: Managed withdrawal is a necessary step prior to drug-free treatment or as the end point of substitution treatment.

OBJECTIVES: To assess the effectiveness of interventions involving the use of buprenorphine to manage opioid withdrawal, for withdrawal signs and symptoms, completion of withdrawal and adverse effects.

SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966 to July 2008), EMBASE (January 1985 to 2008 Week 31), PsycINFO (1967 to 7 August 2008) and reference lists of articles.

SELECTION CRITERIA: Randomised controlled trials of interventions involving the use of buprenorphine to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent. Comparison interventions involved reducing doses of methadone, alpha(2)-adrenergic agonists, symptomatic medications or placebo, or different buprenorphine-based regimes.

DATA COLLECTION AND ANALYSIS: One author assessed studies for inclusion and methodological quality, and undertook data extraction. Inclusion decisions and the overall process was confirmed by consultation between all authors.

MAIN RESULTS: Twenty-two studies involving 1736 participants were included. The major comparisons were with methadone (5 studies) and clonidine or lofexidine (12 studies). Five studies compared different rates of buprenorphine dose reduction. Severity of withdrawal is similar for withdrawal managed with buprenorphine and withdrawal managed with methadone, but withdrawal symptoms may resolve more quickly with buprenorphine. It appears that completion of withdrawal treatment may be more likely with buprenorphine relative to methadone (RR 1.18; 95% CI 0.93 to 1.49, P = 0.1), but more studies are required to confirm this. Relative to clonidine or lofexidine, buprenorphine is more effective in ameliorating the symptoms of withdrawal, patients treated with buprenorphine stay in treatment for longer (SMD 0.92, 95% CI 0.57 to 1.27, P < 0.001), and are more likely to complete withdrawal treatment (RR 1.64; 95% CI 1.31 to 2.06, P < 0.001). At the same time there is no significant difference in the incidence of adverse effects, but drop-out due to adverse effects may be more likely with clonidine.

AUTHORS' CONCLUSIONS: Buprenorphine is more effective than clonidine or lofexidine for the management of opioid withdrawal. Buprenorphine may offer some advantages over methadone, at least in inpatient settings, in terms of quicker resolution of withdrawal symptoms and possibly slightly higher rates of completion of withdrawal.

[Terry Newton]

Suboxone is also an effective pain management medication used in Europe for this purpose though not approved in the United States yet. I believe it is going through some clinical trials currently.

The nice thing about this medication is it has a ceiling, tolerance does not develop, it does not lose effectiveness due to tolerance issues, it lacks any of the cognitive impairment caused by other opiates, it does not have many of the nasty side effects caused by other opiates.

I do hope that there are some studies being done about this in this country as our prescription drug abuse problem is sky rocketing.

[Jack-of-all-trades]

I hate to throw cold water on this subject but I got the notion about a year and a half ago to try to eliminate narcotics from my pain treating regimen and gave Bupe a try. It is not what it is cracked up to be. In the US you have to go to a doctor who has been through a CME course or the equivalent before they can write an Rx. What I found was a lot of lower tier docs were using this as a way of suplimenting their income as it takes multiple visits over a short period of time to take this drug. It is not that it is all that dangerous, just that the patient needs to be monitored closely. None of the usual pain management docs in my area was using it.

You have to be in complete withdrawal before you take the first pill, if not it will put you in complete withdrawal. This is not the fault of the Suboxone itself but of a politician adding stuff to it to make it undesireable as a substitute for narcotics.

There were quite a few contacts via forums that stated it was addictive and that you have to taper off just like a traditional narcotic.

I finially got off 95% of my narcotic by slow taper, but my pain was just to great and was pretty much bed ridden. I finally gave in and bumped my dose back up but since I was working minimally and where I could lay down when needed (advantages of being the owner/boss) The dose then and now are nothing like before it was nothing like before.

[Terry Newton]

I hate to throw cold water on this subject but I got the notion about a year and a half ago to try to eliminate narcotics from my pain treating regimen and gave Bupe a try. It is not what it is cracked up to be. In the US you have to go to a doctor who has been through a CME course or the equivalent before they can write an Rx. What I found was a lot of lower tier docs were using this as a way of suplimenting their income as it takes multiple visits over a short period of time to take this drug. It is not that it is all that dangerous, just that the patient needs to be monitored closely. None of the usual pain management docs in my area was using it.

You have to be in complete withdrawal before you take the first pill, if not it will put you in complete withdrawal. This is not the fault of the Suboxone itself but of a politician adding stuff to it to make it undesireable as a substitute for narcotics.

There were quite a few contacts via forums that stated it was addictive and that you have to taper off just like a traditional narcotic.

I finially got off 95% of my narcotic by slow taper, but my pain was just to great and was pretty much bed ridden. I finally gave in and bumped my dose back up but since I was working minimally and where I could lay down when needed (advantages of being the owner/boss) The dose then and now are nothing like before it was nothing like before.

No politician added anything to this drug. Naltrexone was added by Reckitt Benckiser, who is the United States manufacturer of Suboxone, which is a drug that is marketed specifically for the treatment of opiate addiction and, is used in opiate replacement therapy. Naltrexone is added for the following purpose: Sublingually taken the Naltrexone is processed through the stomach and is passed out of the body. What it is designed for is to keep addicts from attempting to inject the medication which would force the Naltrexone to become active and push the addict in to immediate withdrawals. If you have ever seen opiate withdrawals you would see a person puking, crapping all over themselves, experiencing flu-like symptoms, chills, goose bumps, shaking, nausea, every bone in their body hurts, feeling like they are going to die, etc. It's a hell of a motivation to keep from injecting the drug. As far as the physicians using this as a money maker that is not true in any way, shape, or form. The stigma is horrible enough being labeled an addict, but the Harrison Narcotic Act of 1914 all but tied most physicians hands in treating addiction as any treatment became highly regulated. Physicians are mandated by the federal government to take the prescribing course before they can write any scripts for the medication. Most addicts do not have any money and many states are not paying for any opiate replacement therapies except through Medicaid which is one of the lowest forms of reimbursement available. You are right on one level and that is that the drug can be addictive itself. When it comes to opiate replacement therapy, where brain chemistry has been altered from years of opiate misuse, I would rather see someone be on Methadone or Suboxone than to continue injecting other opiates with the risk of HIV, Hepatitis C, aside from the other consequences that come from long term drug abuse.

If I seem passionate over the issue it is because I have been working with addicts for over 30 years and utilize this medication in the treatment of opiate addiction which is rampant in this country currently. Prescription drug abuse is killing many of our youth from 17 - 24 years old currently.

[Jack-of-all-trades]

No politician added anything to this drug. I'll admit your point. It was a poor choice of words on my part. The point I was trying to get across was that for someone taking narcotics to control pain, does not abuse their meds, and is looking for a way to get off narcotics after their pain issues are resolved, Subutrex/Suboxone (for the pain patient) is a tough way to go. For a drug a drug addict, with an increased likelihood of relapse, I can see its value.

Naltrexone was added by Reckitt Benckiser, who is the United States manufacturer of Suboxone, which is a drug that is marketed specifically for the treatment of opiate addiction and, is used in opiate replacement therapy. Naltrexone is added for the following purpose: Sublingually taken the Naltrexone is processed through the stomach and is passed out of the body. What it is designed for is to keep addicts from attempting to inject the medication which would force the Naltrexone to become active and push the addict in to immediate withdrawals. It doesn't matter how the narcotic gets into your body, if a person has been on opioids orally for pain control, you will be looking at withdrawal. You don't have to inject it. I didn't inject and was in withdrawal the whole time I tried it. I thought, when I tried Subutrex, that I had been off my fentanyl patch long enough that a short acting drug like fentanyl would be out of my system. Was I ever wrong. Plus there is a tendency for the prescribing physician to start out at a low dose and work up to an effective dose keeping the patient in borderline withdrawal till the correct dose is achieved. Depending on the doc's schedule, this could take days. And as you noted, the only way to get out of withdrawal is to wait until your Sub doc gets your level up, or stop the Sub and go back on opioids. As a side note, the meds taste awful and desolves slowly. It could take 30 minutes to desolve making it impossible not to swallow some of the foul tasting slurry.

If you have ever seen opiate withdrawals you would see a person puking, crapping all over themselves, experiencing flu-like symptoms, chills, goose bumps, shaking, nausea, every bone in their body hurts, feeling like they are going to die, etc. It's a hell of a motivation to keep from injecting the drug. As far as the physicians using this as a money maker that is not true in any way, shape, or form. The stigma is horrible enough being labeled an addict, but the Harrison Narcotic Act of 1914 all but tied most physicians hands in treating addiction as any treatment became highly regulated. Physicians are mandated by the federal government to take the prescribing course before they can write any scripts for the medication. Most addicts do not have any money and many states are not paying for any opiate replacement therapies except through Medicaid which is one of the lowest forms of reimbursement available. My point here is that the docs not really into pain and or narcotic management for same seem to actively pursue this type business. It takes quite a few visits with minimal time of patient contact, <5 minutes, to get paid for an office visit. There is even a podiatrist (foot doc) listed in the yellow pages here that Rx Suboxone.

You are right on one level and that is that the drug can be addictive itself. When it comes to opiate replacement therapy, where brain chemistry has been altered from years of opiate misuse, I would rather see someone be on Methadone or Suboxone than to continue injecting other opiates with the risk of HIV, Hepatitis C, aside from the other consequences that come from long term drug abuse.

If I seem passionate over the issue it is because I have been working with addicts for over 30 years and utilize this medication in the treatment of opiate addiction which is rampant in this country currently. Prescription drug abuse is killing many of our youth from 17 - 24 years old currently.I praise your work as it is a noble cause. Those of us who need opioids to live due to circumstances beyond our control should not have to suffer withdrawal, or the astgma of being a drug abuser. The addition of a product to force withdrawal for those taking opioids under the direction of a pain management doc have enough problems.

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Color test

[Katie]

OK, I'm probably on too many narcotics, because I don't really understand the conversation going on here. Are you saying that I have to be in total withdrawal before going on Suboxone? That really seems to be counter productive. The reason I want to be on this (after I no longer need the narcotics for pain), is so I don't go through the misery described above.

Terry, thanks for the PM. I think I need more though, as I am not 'getting it'.

[Justin]

OK, I'm probably on too many narcotics, because I don't really understand the conversation going on here. Are you saying that I have to be in total withdrawal before going on Suboxone? That really seems to be counter productive. The reason I want to be on this (after I no longer need the narcotics for pain), is so I don't go through the misery described above.

Terry, thanks for the PM. I think I need more though, as I am not 'getting it'.

Katie, hopefully this post will help make sense regarding withdrawal and Suboxone...if not, please let me know.

Suboxone is a drug that is usually prescribed to patients that are opioid dependent. Many of these patients are psychologically dependent on opioids (taking an excessive number of narcotic pills a day).

One benefit of Suboxone is that it is a drug that is 1/2 a partial opioid agonist and 1/2 an opioid antagonist. Since Suboxone contains a partial opioid agonist instead a of full opioid agonist like oxycodone, patients do not experience the euphoric high that is often associated with full opioid agonists (another drug to think about is heroin).

The opioid antagonist component in Suboxone is called naloxone. Naloxone is one of the drugs used in emergency departments to treat patients experiencing an acute opioid overdose--naloxone "antagonizes" (displaces) the opioid off of its receptor and promptly takes its spot. When the opioid is no longer on its receptor, the opioid is rendered inactive and the patient no longer experiences effects of the drug.

Suboxone is best absorbed through mucous membranes and the tablet is placed under the tongue to be dissolved; it is not chewed or swallowed. The naloxone component that was discussed above will not enter the bloodstream when Suboxone is dissolved under the tongue. However, if Suboxone is injected, a patient will go into opioid withdrawals because the naloxone will now reach the bloodstream.

I will be taking Suboxone for two months total. Suboxone can be very expensive because there is usually a monthly cash fee for treatment to be paid to the health care provider and then there is the cost of Suboxone medication itself. I started on Suboxone to get off of the remaining full opioid agonists I was on (oxycodone) and to minimize the withdrawals associated with discontinuing opioid therapy, which can be experienced during a "traditional slow taper."

By the way, I am completely off of my oxycodone. :thumpup::thumpup: Two thumbs up like you said! Switching to Suboxone treatment requires one full day free of your prescribed opioids. This frees up the opioid receptors so that the Suboxone now has free receptors to bind.

I hope this makes sense.

[Terry Newton]

Katie:

You only have to be in withdrawals for less than a day to get on the Suboxone. The reason for this is the Naltrexone that is inside the drug (To keep addicts from abusing it) will force you in to immediate withdrawals which would be a waste of the medication. You will see, with the use of the very first dose, the relief that you will get from being on the Suboxone. The rest will be history as you will go through the taper as the doctor prescribes. If you need some further assistance with the explanation I will be glad to help. Please send me a PM and we can talk about it further.

Sincerely,

[Terry Newton]

By the way, I did not see the message that Justin posted prior to my post. He explains it in a more technical fashion than I did and is absolutely correct in the agonist/partial agonist explanation. That is why he will make a great physician soon.

Here is a site that explains the drug magnificently:

Buprenorphine Education: Pharmacology of Buprenorphine agonist antagonist explained and the cuase of withdrawal

It is always amazing when people do not get that this medication is stronger than morphine and can be a very useful pain medication. It is available in many different countries for this purpose. I am against the use of it in the Subutex format as it is highly abuse prone and addictive. The ceiling is a remarkable thing where the drug does not produce the cognitive impairment seen with many other opiates.

I am proud of your desire to become opiate free Katie and it sounds like you have a good physician who will work on this with you.

[Justin]

Terry, thanks for sharing your expertise with the Forum. It is much appreciated.