Advantages of methadone maintenance: 1. Potent opioid; takes away all opioid withdrawal symptoms and cravings. 2. Proven to reduce opioid overdose death rates. 3. Very close monitoring of patient, so it is good for complicated patients who have used high dose opioids for a long time with little sobriety. Disadvantages of methadone maintenance: 1. Daily visits to clinic. 2. Dicult to hold down a job or go to school. 3. Unfortunately very high methadone doses are typically used. Some patients are therefore high on methadone. 4. Dicult to wean o as withdrawal from methadone is particularly severe. Buprenorphine-naloxone: Suboxone, Zubsolv, Bunavail (For ease of understanding I will be using Suboxone to represent buprenorphine-naloxone) Active ingredient is buprenorphine and not naloxone: A lot of people think that Suboxone works because it has the opioid blocker, naloxone, in it.is is not true. Suboxone, Zubsolv and Bunavail’s active ingredient is buprenorphine, which is an opioid. Buprenorphine is not a powerful opioid and has just enough of an eect on the mu receptor to treat withdrawal symptoms and take the craving for opioids away. When Suboxone is used under the tongue, the buprenorphine is absorbed and becomes active.e naloxone does not work when it is taken under the tongue. Naloxone only becomes active when it is injected and if Suboxone is liqueed and injected the naloxone in the Suboxone places a patient in immediate and severe withdrawal. So the reason that naloxone is placed in Suboxone is to prevent patients from liquefying Suboxone and injecting it. A great medication: Buprenorphine-naloxone is a great medication and has been successful in turning millions of lives around. Eight to sixteen milligrams per day is a common dose.e lowest dose should be used which keeps the patient’s withdrawal symptoms away, especially the cravings. At sixteen milligrams the mu receptors are saturated and when a higher dose is given it is only the bad side eects that the patient notices, not necessarily an improvement in cravings or withdrawal symptoms. 14
Stages of treatment: 1. Induction 2. Stabilization 3.Maintenance 4.Weaning
How long on Suboxone? Research does not guide us regarding the duration of treatment with Suboxone.To best treat patients I have divided patients into three categories with regard to duration of Suboxone use: 1. Short term treatment 2. Medium term treatment 3. Long-term or indenite treatment Short-term treatment: e patient is on Suboxone for a few weeks and is rapidly weaned to zero and placed on naltrexone. Medium-term treatment: is treatment is for one to two years and ideally I prefer the dose of Suboxone to be eight milligrams or below. Long-term or indefinite treatment: I reserve this for patients who have concurrent psychiatric illnesses, such as not well-controlled bipolar disorder or schizophrenia. If treatment is going to be indenite, I prefer the dose to be eight milligrams or less. We try to use the lowest Suboxone dose possible, as patients themselves realize they do not need more than eight milligrams and some then decide to sell or share it. Transferring Addiction People unfamiliar with current research, those stuck in the abstinence-based model and fans of the 12-step program, claim that treatment with Suboxone is switching heroin for Suboxone, an illegal drug with a legal one.is is entirely untrue. It can be a typical attempt to make oneself look good and the opioid-addicted patients feel badly about themselves.We have research that shows that Suboxone has a healing eect on the brain and is an excellent bridge from opioid addiction to a life of sobriety. Naltrexone pill and injection (Vivitrol) Naltrexone is a long-acting opioid antagonist and it was initially FDA approved in 2006 for the treatment of alcohol use disorder. In 2010 it was approved for opioid use disorder. Unlike Suboxone, naltrexone does not have an opioid in it and can be prescribed by any physician.To prescribe Suboxone, a physician has to be specially trained in prescribing it. Suboxone and methadone have a lot of research data proving great outcomes in maintaining sobriety, and reduction in opioid overdoses. Studies show that naltrexone works well in patients who are very committed toward their sobriety. In maintaining sobriety and preventing opioid overdoses, Suboxone and methadone are far superior to naltrexone.
Induction: is is the rst stage.e patient is requested to present in opioid withdrawal so the Suboxone can be started immediately.e lowest possible dose of Suboxone that will take care of withdrawal is given to the patient and they are rechecked in two to three days. If the urine drug screen in the next visit is negative, and a dose increase is requested, we do raise the dose. Stabilization: In the next few visits we focus on stabilizing the Suboxone dose. Sometimes the dose is too much and the patient feels that they are nodding during the day, and thus the dose is reduced. Others feel that the dose is insucient. If the urine drug screen is negative and the patient is compliant with counseling, the Suboxone dose is increased. Maintenance: is is the phase when the patient is comfortable with their dose and typically is the longest of all the phases of buprenorphine treatment. Weaning: Depending on the dose of Suboxone that the patient is on, it can take one to four months for a patient to be weaned o Suboxone completely.e dose of Suboxone is lowered very gradually and the patient advised that they will feel opioid withdrawal symptoms for two to ve days, and after that, they are pretty much ne. Essentially all patients realize that they had been unnecessarily nervous about dose reduction, and indeed they felt a little achy and have a bit of insomnia for a couple days, but that after that they were ne. Duration of treatment: is is dierent for dierent people and we try to customize the treatment to each patient. Some patients are on Suboxone for a few months, some for a few years and others indenitely. Just like they had with their choice of opioid, patients get very attached to Suboxone and some become very resistant to dose reduction. Patients want to reduce their doses by one-quarter lms and I reassure them that, just the way they had gotten attached to their drug, they have now latched on to Suboxone and we reduce the dose by half a lm, or four milligrams, every two to four weeks (when the patient is on eight to sixteen milligrams of Suboxone). Side effects: Suboxone can cause drowsiness, constipation, weight gain and leg swelling. And of course dependence as it is an opioid.
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