We have learned two things about medication-assisted treatment: Medication can be an effective part of treatment when used in combination with psychosocial support in a comprehensive program, and medicine alone does not work.
A limited number of agents effectively treat addiction. Physicians may use naltrexone, disulfiram and acamprosate to treat alcohol addiction. For opioid addiction, physicians may use methadone, buprenorphine and naltrexone, as well as a variety of other combination of medications. For nicotine addiction, physicians sometimes prescribe varenicline and bupropion, as well as other medication including nicotine replacement products.
One of the biggest challenges in medication-assisted therapy for opioid use disorders is getting past the idea that treating an opioid addiction with an opioid just swaps one drug for another. Both methadone and buprenorphine are opioids. Both help patients recover. Congress passed the Drug Addiction Treatment Act of 2000 to enable physicians to use an opioid to treat opioid addiction outside of a methadone clinic.
Buprenorphine produces many of the same side effects as other opioids: sedation, headache, nausea, constipation and respiratory depression. It differs from opioids such as oxycodone, methadone, hydrocodone, codeine, morphine and heroin by having a “ceiling effect” on respiratory depression. With full opioids, the more you take, the less you breathe until you stop breathing. With buprenorphine, the more you take, the less you breathe—up to a point, but then the respiratory depression effect flattens out, so people do not die from an overdose, which can occur if they stop breathing. This safety from respiratory arrest is beneficial of course, unless a patient mixes buprenorphine with alcohol or a sedative-hypnotic medication. In that case, a patient can overdose with the combination of buprenorphine and sedatives. This is why physicians should avoid prescribing buprenorphine and benzodiazepines together.
A patient has to be in some withdrawal before starting buprenorphine. I prefer an in-office induction. I want to emphasize that this is not one drug replacing another. Buprenorphine is a component of treatment that comes with structure, support and accountability.
We use medication on an outpatient basis for individuals who have a good support network, and are receiving therapy. If patients are ready to taper off the buprenorphine, we slowly reduce their dose. After they have taken their last dose of buprenorphine, they go through an “opiate washout” period of about two weeks before starting on an opioid blocker such as naltrexone. The washout has to be long enough so that the naltrexone does not induce withdrawal. We conduct a short-acting naloxone challenge, monitoring for withdrawal symptoms to make sure we can move ahead safely.
Naltrexone produces two effects that help opioid dependents: It reduces cravings, and it blocks opioid receptors. The anti-craving effect can be quite robust go now.
Medication-assisted treatment provides a valuable tool in addiction therapy. With good prescribing practices and a comprehensive program, we can help get patients in long-term recovery.