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I always tell my opiate-abusing patients that the most important decision they need to make is whether they want to detoxify off opiates or whether they want to stay on maintenance.  Maintenance involves stabilization on buprenorphine for an extended or permanent period of time.  A third choice that they often present to me is to stay on the drug for a few months (or perhaps a different time period) and then detox.  The drug has been advised for use in all three situations and I will give my feelings about each strategy.

I think it important to point out that this article will contain much more of my opinions and observations and will be relative bereft of evidenced based recommendations.  The main reason for this is that there are very few studies that look at various treatment protocols and their effectiveness in helping people achieve abstinence.  The studies that have been done show that patients maintained on Suboxone stay in treatment longer than patients who are off opiods.   And I'll bet that if we gave patients heroin, they would also stay in treatment even longer.  If treatment is not to help the patient get off all opiods including Suboxone, that treatment seems incomplete

There is no question that a subset of patients need to be on lifetime maintenance.  There seems to be a deficiency in their ability to produce enough natural endorphins to maintain emotional tranquility.  They have chronic irritability, depression and lack of motivation without opiates.  They have unmanageable drug cravings.  It is unclear where the exact neurological disease exists.  It might be in their opiate neurons; it might be from an imbalance in another area.  However, I have no doubt that it is a biological mismatch somewhere.  Replacement of opiates seems to restore optimal emotional health and many patients go on to full productive lives. 

I will maintain these patients on Suboxone for now and for ever

However, I believe that most patients should be given a trial of abstinence prior to being recommended for maintenance.  I do not want to commit them to a lifetime of dependency on a drug, and a dependency on a doctor to prescribe that drug. 

Many doctors will take issue with me on this.  Maintenance has become the standard of treatment for many.  The company stresses this and many doctors assume most patients cannot achieve abstinence.  

Yet, I have seen many patients become and remain opiate free.  It can be done.  What is the optimal time course?

I am aware of only two studies that address an optimal time course for detoxification.  One, from the early 1990's showed a 3 day detox was as successful as a 30 day.  A more recent study shoed a ten day detox was as successful as one that took 40 days.

When I did my first detoxes, I took a few weeks with some success.  Later on, I used the drug for 3-4 days with an increase in the number of patients who became opiate free.

Of course, many doctors now do Suboxone and many patients come with the expectation that na longer time is needed for treatment.  If I try to push their treatment, they get upset and either relapse or find another doctor.  Therefore,  I am back to doing detoxes that last a few weeks; however, I have never obtained the same results that I did when I used a shorter protocol.   

Many patients do not want long-term maintenance but do not want to detox either.  They decide they should be on buprenorphine for some period of time like 2 months or 6 months or a year and than detox.  The reasoning behind this makes a lot of sense.  “If I stay on the drug for a while,” they reason, “ I get to stabilize my life, learn to do things without drugs.  Once things are better, I will be able to get off the drug”   Many doctors also recommend this course.  

The only problem is that, in my experience, this strategy does not work.  The patient stays well for a while than relapses when their buprenorphine dose drops below some critical level.  

In fact, I have seen patients who had undergone a relatively short-term detox with me (1-2 weeks) who stayed clean for several months or longer.  They subsequently relapsed and went to another physician.  This physician maintained them for over 6 months.  They were unable to get opiod free.  

I find if I treat a person for more than a month, the chances that they will achieve abstinence goes down significantly.  Most patients stay on Suboxone or return to their drug of choice.  It seems that the Suboxone causes a physical dependency that is different from that of other opiods.  I have spoken with other addiction physicians and they too have noticed it is harder to come off of the drug after 4-8 weeks

My default approach to any patient is to try to wean them within a few weeks.  I await the appropriate studies to confirm or refute my thinking.  

Other doctors keep patients on Suboxone longer.  My greatest concern is that the relatively easy access to buprenorphine is going to create an entire class of chronically opiod dependent people, a great many of whom might have been opiate-free if they had just tried to tolerate a little more.

But some patients will object to my reasoning.  They'll tell me that they did detox and were sick.  They felt they gave abstinence a chance and abstinence failed.

So I ask the question: What constitutes an appropriate trial of abstinence?

Many people undergo hospital-based detoxifications.  They are discharged but often experience physical withdrawal in the immediate post-discharge period and relapse.  This is NOT an adequate trial. 

However, other people relapse a few weeks later.  They cite irritability, anxiety, and low-grade withdrawal as issues. These are often complicated by cue or stress associated cravings.  They use these symptoms as proof that they cannot detox.  They decide they want to go on maintenance.  

I do not consider these people to have undergone an appropriate attempt at abstinence either.  Withdrawal can be long lasting.  Other articles on this site discuss the various abnormalities that develop.  At this time, I only want to stress that withdrawal can take 3-6 months.  3-6 months of not feeling well can be daunting and many might opt for maintenance to avoid this.  However, this means committing to a lifetime of medication, which seems unfortunate. 

There is a way of shortening the abstinence period.  The use of Naltrexone, an opiate blocker, will accelerate the normalization processes in the brain  Abstinence symptoms  last 1-2 months with this regimen.  Therefore, if someone still felt horrible after a two months on Naltrexone, I would consider them to have had an appropriate trial of abstinence.   

I do not always recommend abstinence first line. 

For young adults who have a career of drug use spanning many years I recommend longer term treatment.  Their histories usually include multiple treatments and,or no time clean.  There are usually co-existing psychiatric problems or a poor home life.  It would be impossible to expect them to stay clean.  Nevertheless, I am always torn because I know they will have a hard time stopping.   Recently, I was asked to put a 16 year-old kid on maintenance that had such a story (use since age 13 and failed treatments). Yet, I wondered how angry that person might be when at 25 he realizes he is on a medication for life.  Is that good care? 

Another type of person who I would consider long-term use is a person with very significant psychiatric problems since withdrawal can be expected to exacerbate this.  Nevertheless, when they are more stable, I would try to wean them off.

If some one is in a exceptionally turbulent two-four week period in their life, I recommend stabilization for a short time until things have stabilized.  Often, however, I found these patients go from turbulence to turbulence.

Despite my recommendations for quick detox, I will treat anyone who wants a longer treatment.  If they do not believe they can accomplish abstinence, they will find some reason to relapse.  I do not want to force them back to their drug of choice.  Hopefully, at some later date, they will detox even if it is more difficult.

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Stuart Wasser M.D.
March 15, 2006Save