Medication Assisted Treatment:
Medication-assisted treatment for opioid dependence can include the use of buprenorphine (Suboxone) to complement the education, counseling and other support measures that focus on the behavioral aspects of opioid addiction. This medication can allow one to regain a normal state of mind – free of withdrawal, cravings and the drug-induced highs and lows of addiction. Medication-assisted treatment for opioid addiction and dependence is much like using medication to treat other chronic illnesses such as heart disease, asthma or diabetes. Taking medication for opioid addiction is NOT the same as substituting one addictive drug for another.
What is Suboxone and How Does it Work?
There are two medications combined in each dose of Suboxone. The most important ingredient is buprenorphine, which is classified as a ‘partial opioid agonist’, and the second is naloxone which is an ‘opioid antagonist’ or an opioid blocker.
What is a ‘Partial Opioid Agonist’?
A ‘partial opioid agonist’ like buprenorphine is an opioid that produces less of an effect than a full opioid when it attaches to an opioid receptor in the brain. Oxycodone, hydrocodone, morphine, heroin and methadone are examples of ‘full opioid agonists’. For the sake of simplicity from this point on we will refer to buprenorphine (Suboxone) as a ‘partial opioid’ and all the problem opioids like oxycodone and heroin as ‘full opioids’.
When a ‘partial opioid’ like Suboxone is taken, the person may feel a very slight pleasurable sensation, but most people report that they just feel “normal” or “more energized” during medication-assisted treatment. If they are having pain they will notice some partial pain relief.
People who are opioid dependent do NOT get a euphoric effect or feel high when they take buprenorphine properly. Buprenorphine tricks the brain into thinking that a full opioid like oxycodone or heroin is in the lock, and this suppresses the withdrawal symptoms and cravings associated with that problem opioid.
Buprenorphine is a long-acting form of medicated-assisted treatment, meaning that it gets ‘stuck’ in the brain’s opiate receptors for about 24 hours. When buprenorphine is stuck in the receptor, the problem ‘full opioids’ can’t get in. This gives the person with opioid addiction a 24-hour reprieve each time a dose of Suboxone is taken. If a full opioid is taken within 24 hours of Suboxone, then the patient will quickly discover that the full opioid is not working – they will not get high and will not get pain relief (if pain was the reason it was taken). This 24-hour reprieve gives the patient time to reconsider the wisdom of relapsing with a problem opioid while undergoing medication-assisted treatment.
Another benefit of buprenorphine in treating opioid addiction is something called the ‘ceiling effect’. This means that taking more Suboxone than prescribed does not result in a full opioid effect. Taking extra Suboxone will not get the patient high. This is a distinct advantage over methadone. Patients can get high on methadone because it is a full opioid. The ceiling effect also helps if buprenorphine is taken in an overdose – there is less suppression of breathing than that resulting from a full opioid.
What is an ‘Opioid Antagonist’ (Opioid Blocker) and why is it Added to Suboxone?
An opioid antagonist like naloxone is a medication-assisted treatment option for opioid addiction that also fits perfectly into opioid receptors in the brain. Naloxone is not absorbed into the bloodstream to any significant degree when Suboxone is taken correctly by allowing it to dissolve under the tongue. However, if a Suboxone tablet is crushed and then snorted or injected the naloxone component will travel rapidly to the brain and knock opioids already sitting there out of their receptors. This can trigger a rapid and quite severe withdrawal syndrome. Naloxone has been added to Suboxone for only one purpose – to discourage people from trying to snort or inject Suboxone.
How is Suboxone Taken as a Form of Medication-Assisted Treatment?
Because it is long-acting (24 hours or more) Suboxone only needs to be taken one time per day. It should be allowed to completely dissolve under the tongue. It comes in both a 2 mg and 8 mg tablet, and a 2 mg or 8 mg filmstrip. The filmstrip is now the preferred preparation because it has less potential for abuse by people with opioid addiction (it cannot be crushed), serial numbers on the filmstrip packs help prevent diversion (trafficking), and the strip dissolves more rapidly than the tablet.
Patients should not eat, drink or smoke for 30 minutes before their dose of Suboxone, or for 30 minutes after their dose of Suboxone. Food, beverages, and nicotine can block the absorption of Suboxone. Chewing or dipping tobacco can seriously impair the absorption of Suboxone and should be promptly discontinued by anybody going through medication-assisted treatment.
There are 5 Phases of the Medication-Assisted Treatment Program
Phase I Detoxification/Suboxone Induction–this phase of treatment typically lasts 3 days and focuses on suppression of the withdrawal symptoms which occur in the first few days after the problem full opioid is stopped. The Northland physician and nurse manage this phase of treatment. The dose of Suboxone is adjusted to make the patient as comfortable as possible. Patients typically spend 5-6 hours at Northland the first day, and 2-3 hours per day on subsequent days.
Phase II Suboxone Intensive Outpatient (SIOP)–this phase of treatment lasts two weeks and begins immediately after completion of Phase I. This phase is specifically designed for the opioid- dependent patient. Education about the biology of the disease, the importance of a sober environment, the management of triggers and cravings and relapse-prevention strategies are emphasized. The dose of Suboxone is adjusted based on the level of cravings. SIOP classes are held from 1-3pm each Monday, Wednesday, Thursday and Friday. On Tuesday evening all SIOP patients are required to attend a Family Education Session from 6-9pm. All patients must complete 10 sessions of SIOP to be eligible for transition to Phase III of treatment.
Phase III Intensive Outpatient (IOP)–this phase of treatment typically lasts 8 weeks. Patients with all types of addiction (alcohol, opioids, cocaine, amphetamines, and polysubstance) come together and participate in group education and counseling sessions three times per week. All patients must attend a minimum of 9 hours of treatment each week to meet the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) requirement for the intensive outpatient level of care. Patients are given the option of a morning or evening schedule for the sessions held on Mondays and Thursdays. All patients (both morning and evening) come together on Tuesday evenings for the Family Education session. Each session lasts 3 hours (with breaks).
Phase IV Continuing Care/Relapse Prevention–this phase of treatment lasts for one year but requires attendance for only two-hour session per week for a group meeting. Most patients find this phase of treatment enjoyable. Patients who are doing well may be asked to assist and encourage those who are struggling in the earlier phases of treatment. A gradual tapering in Suboxone dosage is typically started in the second or third month of Continuing Care and continues to the ninth or tenth month. The goal is to have patients off of Suboxone at least 1 month before completion of the program. Patients who are unable or unwilling to come completely off of Suboxone have the option of continuing in the Post-Aftercare MAT Program or they may transfer their care to another provider in the area who offers medication-only treatment.
Phase V Post-Continuing Care/ Aftercare MAT Program Medical providers realize that some clients will choose to remain on MAT for a duration of time that extends beyond Aftercare/ Continuing Care and are not able/ willing to taper their dose. The Post-Continuing Care/Aftercare MAT Program requires a monthly physician visit along with a monthly One on One counselor visit to observe for relapse, personal struggles, medication compliance, and issues related to 12 Step Recovery. Twice monthly urine drug screens are required. The duration of this program is open ended and the time frame of tapering/ discontinuation is between the client and the physician.