Frequently Asked Questions
The following information reflects my medication assisted program policy for opioid addiction. This information will not apply to other programs. You should seek answers from the programs before you enroll.
- I am allergic to Suboxone. Do you prescribe Subutex?
- What is the starting dose at your clinic?
- What is the duration of your program?
- What is the success rate of your program?
I am allergic to Suboxone. Do you prescribe Subutex?
Suboxone contains Buprenorphine and Naloxone in combination. Subutex (Buprenorphine alone) is no longer manufactured or marketed by that name, but is now available as a generic preparation.
FDA has approved Buprenorphine + Naloxone formulation for outpatient treatment of opioid addiction. The Buprenorphine mono preparation is to be prescribed only under certain restricted conditions.
This is a deliberate decision by FDA to discourage misuse of Suboxone by injection. It balances the benefit of making Suboxone available by prescription, for use in the comfort and privacy of your home, as opposed to having to go to a Methadone clinic to get a daily dose.
Buprenorphine (commonly referred to as Subutex) is only recommended for:
- induction, that is, the first few days of treatment,
- for use during pregnancy,
- for patients who are allergic to Naloxone.
I prescribe Buprenorphine for induction, for a maximum of three days, followed by Suboxone, Bunavail, or Zubsolv. I do not treat patients who are pregnant, or are allergic to Naloxone.
Pregnant patients that are addicted to opioids and or other substances should discuss this with their obstetrician and seek referral to a high-risk pregnancy unit.
Specialized addiction treatment centers or addiction specialists are more likely to accept patients with allergy to Naloxone. Buprenorphine mono preparation may be available at the opioid treatment program where it is dispensed to patients on a daily basis, but not prescribed.
Patients with any evidence of IV drug use are almost never prescribed Buprenorphine mono preparation (Subutex).
True allergy to Naloxone is very rare. Naloxone is the only drug available to reverse the effect of opioids, and is used for treating overdose. If it is on your record that you are allergic to Naloxone, then the medical rescue team or the emergency room may not give it to you for opioid overdose, … that reduces your chance of survival.
So think about it before you go about making false claims about being allergic to Naloxone. Most patients who claim being allergic to Suboxone are describing the precipitated withdrawal that they experienced when they took Suboxone without waiting through the opioid free period of 12 to 72 hours.
Most office based providers will not prescribe Subutex. If you have a sound medical reason to take only Subutex then you might like to try specialized addiction treatment facilities and University Medical Centers.
What is the starting dose at your clinic?
That depends on whether the patient is receiving Suboxone for the first time or is transferring from another practice.
Patients starting Suboxone for the first time are prescribed 16mg/day for the first month, then 12mg/day for the following month.
Patients transferring from another practice or restarting Suboxone after a relapse are started at 12mg/day or the dose that they were on before transfer, … whichever is lower.
Patients who have never been prescribed Suboxone, have to go through in-office induction with Buprenorphine. The first dose of 4mg to 8mg has to be taken in the clinic. They are prescribed Buprenorphine 16mg for three days with instructions to take the lowest dose that prevents significant withdrawal.
They also receive a prescription of Suboxone (or a comparable medication in an equivalent dose), 16mg/day, for 30 days, with instruction to taper their dose as tolerated.
After 30 days, patients receive a maximum of 12mg/day. After one year patients receive a maximum of 8mg/day.
Majority of patients who are serious about recovery should be able to completely taper their Suboxone dose within one year … tapering over one year makes it a very gentle method, … without disrupting normal work or school routine.
Patients who need it for longer period … are not denied the medication, provided they have tapered their dose to 8mg/day or less, and have other social and professional indicators that justify ongoing medication assisted treatment.
What if 16mg (two films/day) is not enough for me?
For a majority of patients 8mg/day is enough to prevent significant withdrawal. One must go through mild withdrawal to force the brain to adapt to a lower opioid dose. However, I do prescribe 16mg/day as an allowance that some people may need to start at 16mg/day.
If 16mg/day is not enough for you, then you need to go to that shiny, big medical center, or find another doctor.
As I have gained more experience treating addiction, I have found that 24 to 32 mg/day (that was strongly recommended by the manufacturer) is excessive.
Now we have more experience from in-patient facilities which prescribe and taper dose based on direct observation of withdrawal … patients almost never need a dose exceeding 16mg/day … most need considerably less. Inpatient facilities taper the dose down to 2 to 4mg within a few days.
There is extensive data from other countries that have state funded health plans for their citizens, … most of their patients receive 8mg/day … even hard core IV drug users, and do quite well.
Even if 8mg/day may not prevent all the symptoms of withdrawal … it is still enough to prevent major withdrawal … and it is still enough to allow patients to function well.
I have an outpatient clinic. I neither have the resources to follow the recommended protocol of seeing patients every few days to adjust their dose, nor are patients willing to pay to be seen every few days. So I have one size fits all approach. My approach works for 90% of patients … the other 10% need to go to a more intensive program.
What is the duration of your program?
Duration is dictated by patient’s progress. I do not have a minimum or maximum duration.
Duration of treatment generally co-relates to the brain injury and alteration of adaptive behavior. For some willpower is not enough … and some do not have the will. There is no reason to dismiss long term treatment as inappropriate … it is far better than the alternative of repeated relapses and continued addiction.
Factors determining duration of treatment are:
- How long the person has used, … longer the use … longer the treatment.
- Quantity being used, … higher the quantity the longer the treatment.
- Other factors … for example poly substance use, multiple relapses.
- Comorbid disorders … coexisting chronic pain, psychological problems, etc.
Patients who want to taper their dose completely within one month, or three months, or six months, … can do so and are encouraged to do so. Some patients are over ambitious they think they can do it … they make good progress initially but are unable to taper off at lower doses. It is very easy to get down to 4mg/day or even 2mg/day … but beyond that it does become difficult.
There are several people in my program who have been on 2 to 4mg a day for a few years. A few have been on 8mg/day for two to three years. For the long term I do not keep any patient who needs more than 8mg/day. They are advised to seek help from some one more qualified.
On the other hand there are patients who are resistant to taper their dose. I expect most patients to come down to 8mg within three to six months. Beyond six months I do not wish to prescribe more than 8mg/day.
Patients are not discharged because they can not taper their dose … they are discharged if they do not taper their dose.
You do not get what you want … you get what you need. And you can get it as long as you need it.
What is the success rate of your program?
The success rate of my program is about 20%.
80% of the patients drop out.
For the remaining 20% … their success rate is 100%.