Process of Treatment
There are three phases of maintenance treatment with Buprenorphine for opioid addiction. These are induction, stabilization and maintenance. A detailed study of the following phases will help one understand how the treatment takes place and unfolds.
This phase is called the Buprenorphine induction and the duration of this phase is something around 1 week. This is the first phase of the treatment where the patient begins the process of shifting from the opioids that he or she is addicted to Buprenorphine. The induction phase is to decide upon the minimum dose of Buprenorphine which works in favor of the patients so that the patient stops or reduces the use of other opioids. The dose should be such that the patient does not experience any withdrawal symptoms, with minimal to no side effects and no uncontrollable cravings for drugs of abuse.
During this phase, the patient should be strictly monitored by a physician who would assess the signs and symptoms of withdrawal or inadequate dosing. Patients are advised not to drive or operate any heavy machinery until their body gets used to the effects of Buprenorphine and the dose is stabilized. The induction protocol differs from patient to patient. It depends upon the opioid to which the patient is addicted to (e.g., short‐ or long‐acting) and whether or not the patient is in active withdrawal at the time of induction.
The consensus panel recommends that physicians administer initial induction doses as observed treatment (e.g., in the office); further doses may be provided via prescription thereafter. This is done to ensure that the amount of buprenorphine located in the physician’s office is kept to a minimum. The patient should remain under observation at the physician’s office for at least 2 hours after the initial buprenorphine dose. For patients not experiencing excessive opioid agonist symptoms after the initial dose, following induction protocols is applicable.
Induction Days 1 and 2: Who Is the Patient and What Does He or She Need?
It is crucial to identify the opioid(s) that the patients have been using. This is because the response to Buprenorphine treatment in individuals dependent on long-acting opioids is more compared to those who have been dependent on short-acting opioids. Upon this depends the choice of protocol. Those patients starting on buprenorphine induction is often physically dependent on a short-acting opioid (which include oxycodone, hydrocodone, heroin) and are in the early stages of withdrawal at the time the first dose of buprenorphine is administered to them.
Patients Dependent on Short‐Acting Opioids
There should be a time gap of 12-24 hours since the last use of opioids before the intial buprenorphine induction dose is administered to a patient who has been dependent on short-acting opioids. The physician would likely notice the early signs of opioid withdrawal (like yawning, rhinorrhea, lacrimation, sweating). Patients who are not in active withdrawal because they have not abstained from using opioids for a sufficient period should be given a detailed explanation of the advantages of waiting. They should be made to wait until they start experiencing the symptoms of withdrawal.
Patients experiencing objective signs of opioid withdrawal and whose last use of short-acting opioid was more than 12-24 hours prior to the beginning of induction can receive the first dose of 4/1-8/2 mg of the buprenorphine/naloxone combination (buprenorphine monotherapy for pregnant women). If the initial dose of the buprenorphine/naloxone combination is 4/1 mg and opioid withdrawal symptoms subside but then return (or are still present) after 2 hours, a second dose of 4/1 mg is generally administered. It should be kept in mind that the total amount of buprenorphine administered in the first day should not exceed 8 mg.
Once the induction phase is over, the stabilization phase sets in the duration of which is approximately 1 to 2 months. The stabilization phase is begun only when the patient experiences no withdrawal symptoms, there is minimal to no side effects and there is no uncontrollable cravings for opioid agonists. As with any pharmacotherapy, the goal of buprenorphine treatment is to treat with the minimum dose of medication that is required to address target signs, symptoms, desired benefits, and laboratory indices while minimizing side effects. Elimination of objective evidence of opioid use (negative toxicology) represents the key target sign for which to strive. The goal is to reduce self‐reported cravings and self‐reported use of illicit opioids. One benefit worth achieving is a self‐reported increase in opioid blockade such that self‐administered illicit opioids induce little or no euphoria. That the treatment is successful is confirmed by a reduction in opioid-positive toxicology specimens.
During early stabilization, dosage adjustments may be necessary, and frequent contact with patients increases the likelihood of compliance. Weekly assessments of patients is suggested until full stabilization is achieved.
The maintenance phase refers to the longest period that a patient is on Buprenorphine, and this period can be indefinite. Physicians might be less vigilant during this period, but significant considerations still needs to be addressed. The psychosocial and family issues that have been identified in the course of the treatment needs to be kept in mind. There are other issues too that will need continual monitoring and that includes cravings for opioids and preventing relapse. There are some other issues too that is related to opioid abuse and which needs to be addressed during the maintenance treatment. Following are the ones:
Somatic consequences of drug use
Family and support issues
Structuring of time in prosocial activities
Employment and financial issues
Legal consequences of drug use
Other drug and alcohol abuse
The frequent presence of some or all of these problems underscores the importance of providing nonpharmacological services to address comprehensively the needs of patients and to maximize the chances of the best possible outcomes.
Long‐Term Medication Management
The design of long term treatment depends partly on the patient’s personal treatment goals and partly on objective signs of treatment success. Maintenance can be relatively short‐term (e.g., < 12 months) or a lifetime process. The success of the treatment depends on the achievement of specific goals that are agreed on by the physician as well as the patient. Following successful stabilization, the decision to whether decrease or discontinue buprenorphine depends on the patient’s decision and confidence to becoming medication-free as well as on the belief and confidence of the physician that tapering would be successful. The factors that are considered while determining suitability for long-term medication-free status include adequate psychosocial support, stable housing and income and the absence of legal problems. Patients who have failed or have not yet achieved these indices of stabilization would have to be in a longer maintenance period. During this, they have to work through all the existing barriers. There is data to prove that longer duration of medication treatment is associated with less use of illicit drug and fewer complications.