Disclaimer: This is for the purpose of education only. Don’t try to self supplement or self medicate.
Clinical Objective
In 2008, I obtained a federal license to prescribe a new, long-acting opiate, buprenorphine, to help detox opiate dependent patients from opioids. I’ve been helping people since with this complicated combination medication, an opiate that is considered 1000 times cleaner than any other opiate, and in some respects 15 to 20 times stronger.
Disclosure
My private practice is in Northern Virginia and you can look me up. I’d be delighted to take care of you or your loved one. I’m also the medical director up an outpatient treatment program in Virginia Beach that takes every insurance imaginable. If you have opiate dependence or addiction or chronic pain, please seek help as soon as possible. Suboxone care can be done by telehealth with me at any time. A physical examination is no longer required for that in the state of Virginia. So, because the door has been opened to virtual care for the patient that requires it, there’s absolutely nothing stopping you from getting this care today.
Introduction
The goal of therapy is to remove the opiates altogether. Unfortunately, many patients who present for this can only change to buprenorphine, thereby, at least, removing traditional opiates from their lives. My goal here is to determine which patients should come off opiates altogether and which patients should not. Hopefully, a literature search on these considerations will not only identify candidates for each group, but will also yield management strategies to guide such care.
Methodology
I used JAMA’s Internet Network and tried to limit my searches to under 10 years. Although buprenorphine has only been available for about 15 years, I identified fifty articles on opiate dependence that were useful as well as federal and SAMHSA guidelines and, of course, the latest 2011 edition of Goodman and Gilman.
Abstract
There is no abstract. The objectives are as follows:To assess the beneficial and harmful effects of full detox using buprenorphine therapy for chronic opiate users.
Background
There is not an opioid dependent patient that does not consider if he or she can come off opiates. They want to know how it might be done and when the care should start. Fortunately, current medications, including the relatively new, long acting opiate, buprenorphine, allow for the safe detox of such patients, especially if their cumulative opiate use has been less than two years. After two years of opiate use, however, receptor load grows so dramatically that detox becomes harder and harder, even using new, long acting opiates like buprenorphine (SAMHSA, 2005). But after two years of abuse is unfortunately when most of them present. After five years of opiate abuse, furthermore, while high receptor loads may stabilize, neurologic and gastrointestinal damage can continue to escalate to degrees of permanence. At that point, treatment evolves beyond the mere treatment of withdrawal and often extends to encompass care for permanent gastrointestinal and neurologic sequelae unfortunately best treated with long acting opiates themselves (Brunton et al., 2011). Clearly, if opiate use goes past the ten year mark, current data suggests that it would be impractical if not unsafe to attempt to detox these patients off opiates altogether(O’Brien, 2008).
So if under two year users should come off opiates entirely and the over ten year users should not, the clinician caring for the five to ten year user teeters on extremely unsteady ground, unable to decide whether to detox fully or not (Farag, 2008). Maintaining the five year user unnecessarily puts the patient at risk for years of unneeded care after reaching the ten year mark. Yet detoxing fully the five to ten year adult may put the patient at great risk for potentially disastrous outcomes ranging from suicidal depression to death (Brunton et al., 2011). This poorly understood gray zone must be addressed formally in order to set guidelines, create realistic goals, design protocols, and avoid dangerous miscalculations and false hopes. The following summary of the literature reviews current guidelines that may help the clinician in assessing whether or not the five to ten year opiate user should be entirely removed from opiates at all plus suggests treatment options that should be considered if detox in this high risk group is to be successful.
Whether Or Not To Detox the Five Year Opiate Patient – Who, What, When, Where, Why, and How
There are many factors that influence the success of opiate detox in the five year user. Deciding candidacy for complete detox is, at present, less a process of checks and balances and more a process of trial and error. So, many physicians steer away from this risky process even if it is in the patient’s best interest. Many physicians sense these patients don’t want to risk feeling sick so why push them. As a result, the federal government has instituted initiatives to encourage physicians and patients to make an effort to reduce or eliminate opiates from their care (Fiellin & O’Connor, 2002). Contracts, reading aloud discharge instructions at each and every office visit that detail the current plan as well as access to medical care in case of depression or cravings, communication between physicians the patient has used, prescription data bank retrieval at every office visit, reliable drug screens, and complete physician availability are all encouraged to minimize risk of relapse (Farag, 2008).
The Who
Age: In the five year opiate user that wants to come off, the age and maturity of the patient clearly drives goal oriented behavior and potentially influences success. In general, young opiate dependent users have greater difficulty coming off opiates altogether, but perhaps should receive more exhaustive attempts to possibly avoid years of unnecessamaary care and expense (Woody et al., 2008).
Personality Types: Type A personality patients have long been known to detox from opiates easier than Type Bs (Sees et al., 2000). Methadone literature exists confirming that strong willed five year users have greater success in coming off and staying off opiates when the proper care is instituted to assist them. Dual care from both a counselor and a doctor will not only identify problems but also accentuate the triggers of motivation that maximize drive (Butcher et al., 2010).
Genetics: Hereditary disorders play an important role producing moderately poor prognosis subtypes due to an interconnected array of personality disorders, anxiety, and depression states (Kuncha, 2007). Chronic anxiety, often familial, drives up the need to self-medicate with opiates (Grant et al., 2004). The user, five year or otherwise, with genetic risk must be identified and should be tapered down cautiously only by a specialist with every adjunct available, pharmacologic and non-pharmacologic (Kendler et al., 2012). Even these physicians consider avoiding full detox if alternative treatment modalities have failed or produced more side effects than the single, detoxing agent, buprenorphine, now available to physicians specially licensed by the DEA with an X number (SAMHSA, 2005). As they are induced and detoxed, the patient discovers benefit from this medication for their anxiety. Standard anti-anxiety medications should then be employed in an effort to remove the patient from buprenorphine. If traditional anti-anxiety cocktails fail or are poorly tolerated, the patient may opt to stay on buprenorphine instead in an off-label setting. If their control is either so remarkable and or well tolerated in comparison to existing standard of care pharmacopeia, physician and patient may elect to maintain this life restoring stability by continuing the buprenorphine (AMA, 2012). The welfare of the patient is a physician’s number one concern.
Chronic depression states like major depressive disorders may also similarly benefit from the single drug, buprenorphine, over traditional failed cocktails of tricyclics, SSRIs, and SNRIs (Watkins et al., 2011). These patients are often suicidal when in poor control. They discover opiates in their first five years of depression so often present in their twenties (Lubman et al., 2009). They know personally the limits of psychotherapy and toxicities of antidepressant medications and electroconvulsive therapy. They have histories of rashes, hangovers, and various degrees of lethargy and malaise caused by traditional anti-depressant care which often drove them to opiates in the first place (Stein et al., 2004). Ongoing psychiatry consultation is strongly recommended in this setting, establishing ongoing lines of communication between the buprenorphine prescriber, psychiatrist, and patient as long as care is provided. These five year users should consider maintenance on buprenorphine in an off label setting until an anti-depressant regimen can be formulated to match the safety and success they find on it (Weiss et al., 2011).
Any personality disorder in general has a component of anxiety associated with it and thus puts this five year opiate user at greater risk for not succeeding in detoxing from opiates ever (Hasin et al., 2011). It is important to identify the degree of chronic anxiety and depression within the disorder because these affective components are what will make detox high risk and maintenance on a long acting opiate perhaps beneficial.
Whether or not there is much anxiety or depression though, dependent personality disorders in particular exist that produce an even greater difficulty in coming off opiates in and of themselves (Hasin et al., 2011). And their co-morbid dependencies like cigarettes, marijuana, and alcohol make these patients easy to identify (American Psychiatric Association, 2000). Dependent personality types unfortunately are particularly refractory to treatment despite their enthusiasm to come off prescribed drugs (Tsuang et al., 1998). The dependent personality patient, especially if they have a component of anxiety or depression to their disorder, should consider maintenance over detox (Kleber, 2008; Sees et al., 2000).
Criminal charges: History or ongoing problems with the law increases the need for early detox (Chandler et al., 2009). Maintenance as the long term plan must be discouraged in all patients in which diversion is suspected. Detox must be stepped up the moment diversion becomes a concern (Fiellin & O’Connor, 2002). The goal should be to disable access to opiates from these people as soon as possible (Chandler et al., 2009).
So, in summary, who to detox in the five year opiate user group? Certainly any patient with any kind of criminal record regardless of risk should be detoxed with an urgency to remove access to opiates as soon as possible, including traditional and alternative opioids like buprenorphine. Who not to detox in this group: all with chronic pain that have failed conservative care that may be more harmful than buprenorphine; all chronic anxiety patients that have failed conservative care that may be more harmful that buprenorphine; every single major depression disorder patient that has failed conservative care that may be more harmful that buprenorphine; dependent personality disorders especially if a long history of other substances of abuse predates their five years of opiate use.
The What
Buprenorphine must be considered for all opiate users who present for care, five year users and otherwise (SAMHSA, 2005). Because of the increased availability of buprenorphine and decreased cost, no patient interested in detox that is a novice to methadone should be induced on that dated long term opiate henceforth (SAMHSA, 2005). The licensed buprenorphine prescriber should stabilize the patient according to current guidelines with an immediate eye to finding the best dose of buprenorphine based on response, compliance with care, and tolerance in a process known as induction. Maintenance follows for at least three months. In that time, the patient should be better assessed for detox vs. ongoing maintenance.
The When
Timing is everything when it comes to decisions involving opiate detox in the complicated patient seeking care. The five year opiate user who intends to come off opiates entirely should be detoxed as soon as possible to avoid hitting ten years of use (SAMHSA, 2005). If the five year opiate abuser is to be detoxed from opiates altogether, there should be no delay in starting at least trials of small tapers as soon as three months of maintenance ends. If risk is questionable or if the patient has greater concerns, a small weekly reduction in buprenorphine dose should be attempted to reassure them of the safety of the process ahead. If their enthusiasm for detox is maintained, the subsequent detox will fare better (Marsch et al., 2005). The small taper also provides the clinician a look into the accruing nature of this long acting opiate’s possible effects in them by carefully questioning the patient about responses felt two, three, and four days after the single taper. Signs of withdrawal that occur in a delayed fashion like this means that a tincture of time as well as adjunctive care may necessary before a similar taper would be tolerated with more permanence. Intolerance means that the taper will be better tolerated in a month (Woody et al., 2008). Intolerance a month later may or may not be sufficient to avoid the taper then even. But the patient is given hope in that trend is in their favor and adjunctive care be stepped up to improve chances of success in a subsequent month (SAMHSA, 2005).
Current and ongoing cravings present a special though massive problem in the detox resistant patient and need to be addressed at every visit if out-patient detox is to work (SAMHSA, 2005). If it hasn’t already occurred, a need to remain on opiates definitely begins some time after five years of use (O’Connor, 2010). Headaches or sleep disturbances uncharacteristic of short term withdrawal may start in these more impaired patients months after every attempt to complete tapering, often leading patients to work ups run by countless specialists. There is limited data on these particularly refractory opiate dependent patients who may need to eventually consider low dose maintenance (Hall et al., 2008).
The Where
The five year opiate dependent patient now has more of a realistic choice as to where to detox safely from all opiate use: home vs. in-patient. Another advantage of the newer, long half-life opiate, buprenorphine, is the ease of which it allows for safe stay-at-home detox (SAMHSA, 2005). It is now generally accepted that compliance and safety can be maintained as an out-patient easier on buprenorphine than with methadone (Mitka, 2003). Follow-up can be adjusted according to progress. But out-patient follow-up, as we learned with years of methadone prescribing, can also be stepped up through times of stress (O’Brien, 2008). And re-checks can increase for non-compliance like resistance to non-opioid medications, or the self-adjusting of prescribed opiates. The ever looming possibility that a physician may increase follow-up regardless of progress minimizes indiscretions (Rosenblum et al., 2003). Compliance with doctors orders, often regarded as suggestions in the out-patient setting, needs to be mandatory with these patients and can be assured by stepping up follow-up or rewarding the patient with less frequent re-checks as the case may be (Rosenblum et al., 2003).
Despite the advent of buprenorphine, many patients will not respond to out-patient care for opiate detoxification (Vastag, 2003). Occasionally necessitating 15-30 day in-patient stays, the opiate detox patient comes to value his out-patient status. A prime candidate for in-patient wellness social detox is in the poly substance abuser. Those patients tend to benefit from longer 30-90 days stays. Still highly regarded today, older studies document effectivity of 180 day courses for even the occasional alcohol only or opiates only “specialist” (Sees et al., 2000).
The Why
While stress management represents one of the most useful tools aiding the clinician in detoxing the five year opiate user, it also calls to mind one of the main reasons why physicians should strive to detox these grey zone patients in first place. Stressors, good or bad, will forever lead opiate dependent patients to take more and more opiates if they have access to them, traditional or non-traditional (O’Connor, 2005). The patients cannot easily substitute ways of dealing with stress outside of making opiate adjustments to alleviate their malaise. Their mental intake assessments tend to reveal psychiatric histories that need not be genetic — abuse within the family unit, loss of a job, and like stressors must be identified thorough questioning before care begins. Methadone advocates induce the five year user onto methadone in an effort to corral the addict but with no hope of removing the methadone once it is on board. With buprenorphine, the stabilization of life is the same, but hope for possible full removal now becomes an option in less than half a year (SAMHSA, 2005).
The How
If the decision to come off opiates altogether is made by the five year user that has no genetic history of psychiatric disorders and no chronic pain, the following tools will facilitate successful tapering. If tapering is going well without harnessing them, they may be used to force a more difficult taper down the line (SAMHSA, 2005). If a taper fails, the following can be revisited again and again, finessing or intensifying parameters of the clinical pearl. And if everything is optimized, and a taper still fails, then a tincture of time itself often produces a different brain with fewer opiate receptors in play to treat (Kuehn, 2005). Thus, realistic hope is always available for the detox patient and everything learned throughout the process can be interpreted as progress.
Compliance:There needs to be an emphasis on not only ordering adjunctive medication and therapy, but monitoring and documenting to ensure that the non-opiate prescriptions were filled and started and that non-pharmacologic physical therapies were pursued, secured, and implemented (SAMHSA, 2005). Only by documenting compliance with non-opiate care can assurance can be made that the ancillary support was actually done and worked or failed (O’Connor, 2010). And if massage, say, failed, perhaps the therapist providing it was not a good fit, or the duration of therapy was wrong. So much can be revised to better optimize non-opiate care with an ever watchful eye to making the next similar, identical, or new taper work even better.
Education:The patient must know that, while there is always a real risk of producing malaise with the process of lowering opiates, malaise can almost always be treated (Hall et al., 2008). Because there is always a risk of depression, lines of communication should guarantee that it can be addressed at any time (O’Keefe, 2003). But even if the doctor on call is not always speedy to respond, patients must be educated to never make upward adjustments on their own (O’Connor, 2005). While increasing opiates can and regularly does lead to death, a lack thereof rarely kills any one (Kleeber, 2002).
A working knowledge of the many downsides to staying on opiates unnecessarily must be taught in order to create a sense of urgency in the detox process. Awareness that a ten year mark approaches with a highly poor prognosis for full detox needs to be heightened if care is to be honest and effective (Kleeber, 2008). The current internet focus on the dangers of opiate withdrawal must see a shift toward the dangers of staying on opiates instead (Krantz et al., 2002). The internet is filled with education provided by street suppliers, foreign and domestic, highly threatened by the advent of new modalities of successful detox. Internet models of opiate dependence range from dated theories on replenishment teaching a need to get back on opiates when they run out instead of the receptor models modern psychopharmacology continues to refine. Patients must be cautioned against their internet sources’ reliability (Hall et al., 2008).
Stress: A dysfunctional relationship, a bad job; great news about a loved one graduating from college — all of these are stressors driving up opiate use in these patients (Butcher et al., 2010). Lowering if not eliminating something of stress with permanence will make a repeat taper that failed before an entirely different event the next time it is attempted, and subsequent success can be associated with even the merest of change.
Access: Moving the opiate dispensing role onto a loved one like a mother, father, or spouse takes away the “I-like-to-take-pills” factor that opiate users do not deny out of the equation. Clearly easier with the long half life opiates because of once or twice a day dosing, even bank vault storage is possible in the patient continually “losing” their medications (Hayes & Brown, 2012).
Non-opioid medications: The first generation SSRI Paxil lowers opioid catabolism and thus facilitates detox from opiates (Rokhlina et al., 2007). The anti-emetic, mildly anti-psychotic promethazine (Phenergan) augments opiate strength and thus allows for opiate dose reduction (Brunton et al., 2011). Cocktails of NSAIDs in combination with muscle relaxants like Flexeril and Soma are being used in prisons that do not allow opiates of any kind, long acting or otherwise, to stabilize if not detox opioid dependent inmates with anecdotal success (Chandler et al., 2009). Clonidine, long known adjunct in opiate detox, has yielded success either alone or combination with other agents (Collins et al., 2005).
Co-abuses: The details on substances abused in the past should be secured at a thorough intake assessment (SAMHSA, 2005). Alcohol dependency often precedes the years of opiate abuse in either group. The looming threat that they may return to alcohol is ever-present, and these patients are high risk (Hasin et al., 2011). If caught early, traditional opioid dependence can be managed effectively with a treatment opiate like buprenorphine which may prove to reduce or even eliminate any alcohol cravings as well (Ling et al., 2010; Heinz et al., 2005). The simultaneous abuse of alcohol with opiates with benzodiazepines, although not the rule fortunately, makes detox particularly difficult. Many combination benzo/opiate users feel particularly enabled to take both types of medications because their well intentioned but unread psychiatrist is prescribing them (Hayes & Brown, 2012). But hope and education make these patients surprisingly easy to treat if not fully detox. They want off, and are gratified when a physician finally steps forward to start reducing the pharmacopeia.
While marijuana famously offsets many of the discomforts of immediate opiate withdrawal (Tsuang et al., 1998), no evidence exists to suggest that it can help detox a five year user off opiates altogether. Cigarette smoking too has been known to increase opioid catabolic metabolism, thus driving up opiate use (Krantz & Mehler, 2004). Alcohol abuse makes opiate abuse all the more risky to continue, making opiate cessation all the more desirable (Hasin et al., 2011). Newer agents like buprenorphine have been shown to lower cravings for both alcohol and opiates in the poly-substance abuser (Brunton et al., 2011).
Weight: Weight loss in the obese using non-impact exercise and eating modification curbs opiate pharmacokinetic demands (Brunton et al., 2011). Weight loss in the obese guarantees a reduction in opiates not only because smaller patients need less medication, but also because joint and back pain is reduced (Rosenblum et al., 2003).
Exercise: Fat reduction also optimizes detox conditions. Exercise, along with modalities like Bickram and other forms of yoga as well as healthier eating, lowers fat lowers unnecessary body weight that will otherwise heighten perception of pain and thus opiate demands (Marsch et al., 2005). Increasing exercise in and of itself has long been associated with the successful removal of exogenous opiates because of the release of endogenous body opioids known as endorphins (Brunton et al., 2011).
Health: Wellness derived from fully controlled blood pressure, diabetes, and non-euthyroid states makes opiate detox not only easier but safer. All aspects of medical, mental, and social wellness ranging from fully treated illnesses in every organ system to a healthy sex life will help a patient lower opiate requirements (Meston & Frohlich, 2000).
Sleep: Optimizing sleep facilitates the tapering of opiates. Poor sleep increases catecholamines, driving up physiologic opiate requirements including the perception of pain (Redline et al., 2004). Increasing sleep in the non-sleep disorder patient may also lower opiate demands and thus help detox (Brunton et al., 2011). Inducing good quality REM sleep at bedtime isn’t just a matter of taking medication. Hour of sleep habits like smoking must be identified and revised. Smoking tobacco has a stimulating effect and cannot be allowed at bedtime (Wilens et al., 2008). Naps, if there is no history of insomnia, are part of a restful lifestyle and will allow for improved tolerance to minimizing opiates (Rosenblum et al., 2003).
Counseling: Studies continue to prove that intensive in-patient and out-patient counseling is required by opiate dependent patients (Weiss et al., 2011). The higher risk five year user must maintain this therapy regularly whether their plan is maintenance or complete detox. It is in the patient’s best long term interest to resolve maladaptive thoughts and behaviors that stimulate opiate dependance (Butcher et al., 2010).
Physical Therapy: Literally dozens of licensed and non-licensed adjuncts are available to assist in detoxing opiate dependent patients including the higher risk, five year user. Non-pharmacologic modalities including physical therapy like acupuncture, massage, and countless others, assist with not only stress management, but also optimize the results of weight therapy, smoking cessation, and sleep reform (Feather, 2012).
Motivation: Motivation of the client to change must begin with a commitment of the physician to change (Wakefield, 2004). The motivation of the patient and doctor alike will improve treatment outcomes when either dose lowering or complete detox is chosen as the course of action. However it is important to keep in mind that many five year or even less users have no interest in coming off the detox medication because, off label, they effectively treat their chronic anxiety or chronic depression or ADD or a combination of these disabling disorders. As aforementioned, there are possible advantages of a single medicine like buprenorphine over a pharmacopeia for these disorders: less tolerable drugs, greater long term side effects including well documented reduction of response to many of them with time. The physician and the patient must have a well formulated meeting of the minds. Motivation for the plan to detox, if that be the case, must be very deliberate and very shared with doctor and client for tapering to work as well and safely as it possibly can.
Tools now confirmed to assist in opiate detox range from smoking cessation, weight loss, non-opiate medications including Paxil, Phenergan, clonidine, muscle relaxants and NSAIDs to lower opiate need, non-opiate medicine including blood pressure and cholesterol treatments, and non-opiate psychiatric prescriptions to treat depression, anxiety, and ADD.
Conclusion
In conclusion, the medical literature supports that at least switching five year opiate dependent patients that want to come off opiates altogether over to buprenorphine at least represents progress because it has been shown to be a safer opiate than the rest (Woody et al., 2008).
Should a realistic prognosis for fully detoxing the five to ten year opiate user be considered poor? It varies from patient to patient. But if chances for complete removal from opiates of the five to ten year opiate user are to be optimized, a buprenorphine preparation like Subutex or Suboxone must be considered SAMHSA, 2005).
Type A personalities can receive a better prognosis for success when attempting to come off reliance on opiates (Sees et al., 2000). Chronic anxiety and major depressive patients should be discouraged from full detox especially if there is any suicidal history (Hall et al., 2008). These clients should be reassured in the safety of remaining on a long-acting opiate especially if previous pharmacopeia was either extensive, ineffective, or associated with any end organ risk.
A growing body of evidence exists supporting the need to make a safe attempt at fully tapering five year opioid dependent patients off all opiates altogether.
Discussion
Opiate dependence is accelerating in all population groups. On the rise in even childhood populations, the full removal from opiate addiction remains the focus of the growing body of medical literature. The care for the opiate dependent adult varies from maintenance, especially with regard to chronic pain patients, to full detox off any form of opiate reliance. The decision for which extreme of care the patient does receive is heavily influenced by patient demands and an unfortunate and growing pharmaceutical ignorance in opiate prescribers. Instead, the decision for what kind of care the patient should receive should more appropriately be influenced by a working knowledge of evidence based care and prognosticating co-morbidities available to all physicians today.
Chronic pain, chronic anxiety, and major depressive patients who have become dependent on opiates for five years are clearly the exception and should strongly consider with the guidance of an expert clinician staying on long half life opiates like buprenorphine for life. In contrast, all other five year users should consider at least trying to fully detox with an expert physician. While no formal compendium on the matter of actual candidacy exists dictating the capability of a patient to detox from opiates with long term success, the evidence and therapeutic modalities now available seems overwhelmingly in favor of at least trying to safely detox the gray zone five year user as soon as possible.
Within the limits of current available data, of all the grey zone group of five year users, all should attempt detox off all opiates altogether as soon as possible as long as there is no history of chronic pain, chronic anxiety, major depression, or dependent personality disorder. The dose should be lowered to the least effective dose as soon as possible in all patients choosing maintenance over detox. Maintenance patients should be watched closely for tolerance and response with a great focus on stability in all parameters of health including weight. Detoxed patients should be followed well after the final tapers for any subtle signs of atypical headaches and sleep disturbance that may indicate that physiology has been disturbed with greater permanence than expected by the five years of opiate use.
References available on request.
