Before making the decision of where or how to get help for your opiate use, abuse, or addiction, one must first acknowledge that they have a problem with their use of opiates. Like most addictions, (be it alcohol, marijuana, cocaine, or meth) until the person struggling with this overuse or addiction or dependence can get help one of two things must happen:
- They must acknowledge they have a problem and ask for help or at least be willing to get help.
- Loved ones can do an intervention where the ultimatum is placed, lovingly, that they have reached the end of the road – no more financial support unless they go to treatment.
This article in Journal of Addiction Medicine Sept/Oct 2014, “Unobserved Home Induction onto Buprenorphine,” looks at the studies to date on this topic. You can read the article here… They looked at 10 studies and 9 provider surveys and while the studies were weak and seemed to have bias, they found no significant differences. International guidelines in the US, United Kingdom, France, and Australia emphasize clinician or pharmacist observed induction with only Denmark endorsing unobserved induction.
As a board certified addiction specialist, and the physician for hundreds of Buprenorphine opiate addicts over the past 5 years (less than 100 at a time), I can clarify this issue. Most of the opiate addicts today are using heroin daily and cannot go 24 hours without using or they suffer severe withdrawal symptoms. They are in bondage to the drug that once was their savior! They will do almost anything to avoid going into that withdrawal, hence the tremendous pressure to get money and opiates no matter what. This becomes the primary goal period. Few can juggle this for long unless they have plenty of money.
The second group that is addicted or dependent on opiates are the pain patients or those who have been on pain opiates for more than a month or two. They are in the same situation; the withdrawal symptoms are so severe that it feels like the pain is getting worse. Indeed, because your body adapts to the opiate use (tolerance) the patient or person needs more and more to get the same effect. What 99% of these “pain” suffering individuals learn (eventually) is that once we start weaning down the dose of opiates, they actually end up with less pain. Opiates are a wonderful drug class for acute pain and generally a bad idea for chronic pain. If you have terminal cancer or some other devastating injury, obviously take all the opiates and other pain meds you can to get relief- I am not advocating suffering.
So the question raised in this article is this: can we give our opiate addict the Buprenorphine prescription and have them fill it, then at home wait until they are in enough withdrawal to start taking the Buprenorphine, or should we have them arrive in our office in withdrawal, give them the first dose and then have them fill their prescription?
I will tell you that with most of my patients, the first choice will fail and here is why. If I am at home getting high on heroin or pills, (for which I usually must struggle to find the money to obtain) and I’m given let’s say 60 Buprenorphine 8 mg tabs (value $900 – $1800), what are the odds that I will allow myself to get to that dreaded feeling of severe withdrawal before taking one? My heroin or pill dealer would gladly take my Buprenorphine in exchange for all the heroin or pills I would need for the coming month.
Once you have induced the opiate patient (we do a scoring of withdrawal symptoms that is near impossible to fake) the fact that the person has started Buprenorphine, now makes success much more likely. Buprenorphine is a partial agonist (meaning it gives a partial opiate effect) and a partial but very strong opiate blocker (meaning that once you are taking 16 mg a day it is very unlikely you will experience the “high” from using opiates).
In addition to insisting on an observed (in office, in our case) induction, it is advisable that someone other than the patient hold the Buprenorphine for the first month or longer if needed. This removes the temptation of selling the Buprenorphine (or Suboxone, Zubsolv). If outpatient treatment fails, or your opiate user has severe mental health or other addictions besides opiates, it may be best to have them observed inpatient at an addiction treatment center where you spend several days or weeks.
If you are prescribing Buprenorphine without following urine drug screens, you are also potentially just contributing to the problem of diversion, where these patients are selling their Buprenorphine and you may be just as bad as the drug dealers on the street. I know as a physician we are taught to believe our patients and we are trying to help, but seriously, think of the addict and be realistic. Not all patients are diverting and indeed we save lives with treatment, which is why we do this.
I obviously am not a fan of home induction, simply because it is risky and I am certain there will be many more cases of diversion. Home induction is not the current standard of care, although I fear we are headed that way, and as a result we shall see more and more Buprenorphine on the black market.
For an appointment with Dr Paul Thomas (opiate users age 30 and under) contact Fair Start here…