Buprenorphine: Tips for Induction & Maintenance Use
DISCLAIMER
The content provided in this Substack post is for entertainment and informational purposes only and is not intended to serve as medical advice. The views and opinions expressed herein are those of the writer and should not be taken as definitive or authoritative. Readers should not rely solely on the information provided in this post to make decisions about patient care. Instead, use this content as a starting point for further research and consult a qualified healthcare professional before making any changes to treatment or medication regimens.
What is Opioid Use Disorder (OUD)?
Opioid Use Disorder is a medical condition characterized by the compulsive use of opioids, even when they cause harm. Opioids, originally derived from the opium poppy, include both illicit drugs, like heroin, and prescription pain relievers, such as oxycodone and morphine.
An opioid crisis is sweeping across many parts of the world, and it's critical that we address it with both compassion and knowledge. In this post, we'll delve into the dangers associated with opioid use disorder (OUD) and one of the most management strategies.
Dangers of Opioid Use Disorder
Physical Health Impacts: Chronic opioid use can result in respiratory depression, which could lead to fatal overdoses. It can also cause nausea, vomiting, and a weakened immune system.
Mental Health Consequences: Opioids can induce feelings of depression and anxiety over time. This, coupled with the physical dependencies, can lead to a vicious cycle of increased drug use.
Socio-economic repercussions: Opioid dependency can strain personal relationships, result in job loss, or lead to criminal charges for illicit drug use or prescription forgery.
Withdrawal Symptoms: Abstaining from opioids after developing a dependency can lead to severe withdrawal symptoms like pain, diarrhea, nausea, and mood swings.
Approaches to Managing OUD:
Managing OUD requires a variety of techniques (think biopsychosocial model). A more comprehensive approach to detox can be found here. With that said, today’s post will focus on a specific management approach: buprenorphine.
Until relatively recently prescribing buprenorphine required an “X waiver” from the DEA. But, this requirement has been removed in an effort to eliminate barriers to treatment. From a pharmacological perspective, we are quite limited in management of opioid use disorder, so this recent elimination has potential to be very helpful for patients.
Other pharmacological tools for management of OUD, which will not be the focus of this post include methadone & naltrexone.
So what is Buprenorphine?
Buprenorphine is a highly competitive partial opioid agonist, which means it binds to the same receptors in the brain as opioids. What makes buprenorphine unique is both the partial agonism coupled with it’s high binding affinity. Due to it’s partial agonism, it doesn’t produce the same euphoria or sedation (like heroin or fentanyl). It’s partial agonism also makes it relatively safer in overdose compared to full agonists like methadone.
On the other hand, it’s high binding affinity for opiate receptors allows it to block/blunt the effects of other opiates, eventually reducing the drive to use them. Incidentally, it binds so competitively that it will actually displace full agonists from opiate receptors and effectively precipitate withdrawal symptoms.
note: management of precipitated w/d is a topic worth it’s own post, so keep an eye out for that in the future.
Buprenorphine's Role in OUD Management:
Buprenorphine can be utilized in the short term as a means of alleviating withdrawal symptoms, or as a long term therapy for the elimination of cravings. You can think of alleviating withdrawal symptoms as phase one & the elimination of cravings as phase two.
Phase 1: Initiating Buprenorphine Treatment
Prior to administering buprenorphine, it is imperative to ensure that the individual is in the early stages of opioid withdrawal. In many places, the standard is to utilize various comfort medications such as clonidine, zofran, bentyl, robaxin, ibuprofen, imodium etc and other comfort medications to manage symptoms while monitoring with the Clinical Opiate Withdrawal Scale (COWS). Typically if COW score >11 it is safe to administer.
Administering buprenorphine too early in the withdrawal process will precipitate withdrawal symptoms. This occurs because of buprenorphine’s partial agonism. The abrupt transition from total saturation of opiate receptors to partial saturation due to displacement (& replacement) of a full agonist like fentanyl or heroin to a more competitive partial agonist creates an immediate withdrawal effect.
There are a number of ways to go about actually initiating buprenorphine & may vary depending on treatment setting. Administering an initial dose of anywhere from 2-8mg can be appropriate depending on patient presentation. However, in the outpatient setting it is rare to administer more than 8 mg on the first day of treatment. In the inpatient detox setting, it is very common to see 12-16 mg administered on the first day, depending on presentation.
Phase 2: Stabilization on Buprenorphine Maintenance
Initially, it is all about managing withdrawal symptoms. After a few days, withdrawal symptoms will have significantly lessened & the focus becomes elimination of cravings.
Think about it. If a patient has an opioid addiction, then the detoxification portion of treatment is really all about eliminating the compulsion (via withdrawal symptoms) to use. In terms of craving the high, it doesn’t do anything at all. Individuals who have completed detox are very likely to experience cravings, particularly if using has been a means of self medication or a learned maladaptive coping skill. This is where buprenorphine maintenance comes in. The entire purpose of maintenance treatment is to use the lowest effective dose to eliminate cravings… aka if a patient complains of cravings on 8 mg daily, then that dose is not working out & they are at a very high risk of relapse. Typical maintenance doses range from 8-24 mg daily. Finding an appropriate maintenance dose is really pretty simple & doesn’t require a lot of focus for the purposes of this post. If for some reason 24 mg/day isn’t doing the trick, they may benefit from methadone.
Subutex vs Suboxone
What are the differences?
Subutex is buprenorphine. Suboxone is a buprenorphine/naloxone combination at a 4:1 ratio (4 mg buprenorphine to 1 mg of naloxone). Because naloxone is not bioavailable sublingually, but is via IV/IM/intranasally it is the perfect additive to prevent diversion or abuse.
For this reason, it is very common to see subutex utilized in hospital settings (where administration is supervised) and suboxone utilized in outpatient settings.
Conclusion
In conclusion, Opioid Use Disorder (OUD) remains a significant health challenge with far-reaching impacts. Its dangers span physical, mental, and socio-economic domains. However, with evolving medical knowledge and interventions, management has become increasingly sophisticated. Buprenorphine stands out as an effective tool for the management of OUD. By understanding its pharmacological profile and its proper administration, practitioners can significantly improve the quality of life for individuals afflicted with OUD. It's crucial to recognize the differences between buprenorphine formulations, such as Subutex and Suboxone, to employ them effectively in diverse treatment settings. As our understanding deepens and treatments advance, hope remains for those battling this disorder and the communities affected by it.