If you have much give of your wealth; if you have little give of your heart. --Arabian Proverb
This section discusses the use of buprenorphine for the medically supervised withdrawal (detoxification) from short -acting opioids and from OAT with methadone or LAAM. The goal of medically supervised withdrawal from opioids is to provide a smooth transition from a physically dependent to a physically nondependent state. A patient can then engage in further rehabilitation with or without the use of opioid antagonist treatment to assist in relapse prevention. Before considering the use of buprenorphine for withdrawal from illicit opioids or to discontinue OAT, a patient's appropriateness as a candidate for withdrawal or cessation must be determined at the time of assessment. Withdrawal treatment must be followed by long-term drug-free, or naltrexone, treatment in order to minimize the risk of relapse to opioid abuse. It should be noted, however, that absent a compelling need for the complete avoidance of all opioids, long-term maintenance treatment with buprenorphine to be preferred in most instances to any form of detoxification or withdrawal treatment.
Buprenorphine for Detoxification From Short -Acting Opioids
Detoxification in patients addicted to short-acting opioids is only a part of the overall approach to treatment. The purpose of using buprenorphine for detoxification from short-acting opioids is to provide a transition from the state of physical dependence on opioids to an opioid-free state, while minimizing withdrawal symptoms (and avoiding side effects of buprenorphine).
The consensus panel recommends that patients dependent on short-acting-opioids be inducted directly onto buprenorphine/naloxone tablets. Before initiating buprenorphine induction, patients should have discontinued the use of illicit opioids and should be exhibiting the early symptoms of withdrawal.
An initial 4/1 mg dose of buprenorphine/naloxone is recommended. This dose can be followed in 24 hours with a second dose of 4/1 mg, if indicated. Over the next 2 days, the dose of buprenorphine/naloxone should be increased to 12/3 -16/4 mg per day. The objectives of induction should be to stabilize the patient as rapidly as possible, to minimize any withdrawal symptoms, and to eliminate further use of illicit opioids.
Only after a patient has completely discontinued use of illicit opioids should the dose-reduction phase begin. Unless a patient is in a controlled environment (e.g., a hospital or residential setting), cessation of opioid use should be documented with a negative toxicology test for illicit opioids. If a patient is unable to discontinue illicit opioid use, as documented by negative toxicology results, a further period of stabilization or maintenance should be considered.
Dose Reduction Phase
Long -Period Reduction. The literature suggests that the use of buprenorphine for gradual detoxification over long periods is probably more effective than its use for rapid detoxification over short or moderate periods; however, little research has been conducted on this use of buprenorphine. Patients who are unwilling or unable to engage actively in rehabilitation services without agonist support may not be appropriate candidates for short-term detoxification; however, such patients may benefit from long-term detoxification (or, even more so, from maintenance treatment).
Moderate -Period Reduction. Patients without a compelling need to undergo short-term detoxification, but with a desire to become opioid free and to engage in rehabilitation aimed at an opioid-free lifestyle, can be detoxified over a 10- to 14-day (or longer) period by gradually decreasing the initial stabilization dose of buprenorphine (usually 816 mg per day) by 2 mg every 23 days. It is extremely important that patients engage in rehabilitation programs during the detoxification period and that they remain engaged in such programs after the conclusion of the detoxification protocol.
Short -Period Reduction. Patients with a compelling reason to achieve an opioid-free state quickly (e.g., impending incarceration, foreign travel, job requirement) may have their buprenorphine dose reduced over 3 days and then discontinued. When compared to clonidine for the treatment of short-term opioid withdrawal, buprenorphine is better accepted by patients and more effective in relieving withdrawal symptoms (Cheskin et al. 1994). Relapse rates and long -term outcomes from such rapid opioid withdrawal using buprenorphine have not been reported, however. Studies of other withdrawal modalities have shown that such brief withdrawal periods are (1) unlikely to result in long-term abstinence and (2) produce minimal, if any, long-term benefits in the treatment of patients dependent on opioids.
Buprenorphine for Discontinuation of Opiate Agonist Treatment
The use of buprenorphine (either as buprenorphine monotherapy or as buprenorphine/naloxone combination treatment) to taper off Opiate Agonist Treatment with methadone should be considered only for those patients who have evidence of sustained medical and psychosocial stability. Requests to provide pharmacological withdrawal with buprenorphine or buprenorphine/naloxone should be entertained with caution. Only a small proportion of patients who have achieved stability with Opiate Agonist Treatment are likely to maintain abstinence without medication. Ideally, this decision would be made in conjunction, and in coordination, with a patient's Opiate Treatment Program. The option of continued maintenance with buprenorphine/naloxone if withdrawal proves unsuccessful should be discussed.
Short-period discontinuation is not recommended unless there is a compelling need for rapid discontinuation.
In general, patients who are clinically stable and are being slowly tapered off methadone maintenance treatment experience little difficulty until the daily methadone dose reaches 30 mg or less. As the daily dose drops below 30 mg, opioid withdrawal symptoms often emerge between methadone doses. Additionally, the euphoria-blocking and anticraving effects of methadone are much diminished at this low dose level.
Discontinuation of Buprenorphine/Naloxone
When the decision is made to discontinue buprenorphine/ naloxone combination treatment, the daily dose should be decreased gradually over a predetermined period or at a rate negotiated by the patient and the physician together.
Withdrawal symptoms may emerge as the buprenorphine/ naloxone dose is decreased. In this event, the taper may be temporarily suspended.
As with the protocols described above, discontinuation of buprenorphine/naloxone combination treatment may be performed over short periods (e.g., 3 days), but this approach should be used only in the presence of a compelling urgency to discontinue buprenorphine/naloxone in this manner; discontinuation over a longer period is the preferred manner.
References: (1) Clinical Guidelines For The Use of Buprenorphine In The Treatment of Opioid Addiction (TIP 40) Chapter 4 pp. 58-63 http://buprenorphine.samhsa.gov/Bup Guidelines.pdf
Compiled and Edited: Deborah Shrira Dated: 14 April 2007