This remarkable change in the laws governing prescription use of narcotic medications will provide opiate addicts with improved access to opiate maintenance therapies. There are close to a million chronic opioid addicts in the United States and less than 25 percent of them seek treatment. Those who do seek care have relatively poor outcomes in traditional abstinence-based treatment programs (although this has not been the case at Hazelden, where opiate addicts have achieved outcomes similar to the general patient population). The tremendous medical, social and legal consequences of heroin addiction and the limited success of standard treatment settings fostered the development of maintenance therapies.

Maintenance therapies use a medication within the same class as the addicting drug to prevent intoxication, withdrawal, and illicit use. These therapies also stabilize some of the social and behavioral consequences of heroin addiction. Methadone is the most widely recognized medication used for maintenance therapy. It has been used worldwide and is the most common treatment for heroin addiction used in the United States.

Methadone maintenance therapy, however, does have its problems. Methadone is addicting, can be used for intoxication, and is sometimes sold for profit. Controversy in regards to recovery status also plagues recipients of methadone; those who are successfully involved in this form of treatment are often not considered abstinent. Also, U.S. law requires that addicts who are prescribed methadone must acquire it from methadone clinics. This can be very inconvenient, often resulting in attending the clinic five days a week to obtain doses of methadone.

Physician training to limit abuse
Buprenorphine will offer an alternative, safer medication for maintenance therapy of opiate dependence. It is an opiate medication that has been available since the early 1980s in an injectable form for pain relief. It is made from thebaine, a derivative of opium poppies. Buprenorphine can be used for intoxication, but only produces a partial opiate high when compared to heroin or methadone. It can cause physical dependence, tolerance, and withdrawal. Some people will abuse it, but regulatory efforts and training of physicians should limit access and prevent wide scale abuse. Only properly trained physicians will be allowed to prescribe it.

Buprenorphine will be available as a sublingual tablet in two different forms: Subutex, made of only buprenorphine, and Suboxone, a combination of buprenorphine and naloxone. Suboxone, rather than Subutex, will be used for maintenance therapy in an attempt to prevent the risk of injecting buprenorphine for its intoxicating effects. Both medications are intended to be used sublingually, not intravenously. Suboxone was developed in this combination so that if it is injected, the naloxone becomes effective and blocks opiate receptors. When this occurs the individual cannot become intoxicated. In fact, it's possible it could cause sudden, severe opiate withdrawal symptoms. This should prevent illicit intravenous use of Suboxone.

The law allows for office-based prescribing of buprenorphine in the privacy of the physician's office. This will improve the addict's ability to access this type of opiate addiction treatment and is much more private than methadone clinics. Addicts in buprenorphine maintenance treatment can obtain weekly prescriptions and only need to use the medication once every day or two. It is believed that more opiate addicts will seek maintenance treatment as a result. Numerous studies have demonstrated buprenorphine to be as effective as moderate doses of methadone for maintenance therapy of opiate dependence. It appears to cause fewer side effects than methadone and is safer in the event of an overdose. However, there have been reports of death by overdose when buprenorphine is combined with other sedating drugs.

Maintenance therapies are not provided at Hazelden facilities. We use a Twelve Step, abstinence-based treatment model. We treat opiate addicted patients and will be using buprenorphine for opiate detoxification. It is a very safe, effective medication for opiate detoxification and appears to provide more comfort to opiate addicts during withdrawal than do the most frequently used medications, such as methadone and Clonidine.

Physician prescribing and release of buprenorphine for office-based opiate treatment is not without controversy. As described, buprenorphine is addictive and will be abused. It will be diverted from prescribed use and sold on the street. Some people on maintenance therapies will continue to use other drugs and alcohol, which would maintain active addiction. Thus, buprenorphine is far from a panacea.

Physicians are being trained to select only stable patients for office-based buprenorphine treatment. This would exclude addicts who use other substances, those with little psychosocial support, and those with other significant medical or psychiatric problems. Safety and risk reduction are being emphasized in physician training. This screening process will limit the office-based use of buprenorphine in an appropriate manner. It will also help physicians who have little experience in addiction treatment as they enter into the unfamiliar territory of prescribing opiate medication.

The law requires physicians to have the capacity to refer patients for appropriate counseling and ancillary services. So the provision for at least some type of addiction treatment service beyond the isolated use of medication is in place. But this "experiment" in physician prescribing for opiate addiction may hinge on these services. We've seen other medications fail for the treatment of addiction and have learned that alcoholics and addicts don't necessarily comply with medications as prescribed. Methadone maintenance is plagued by alcohol and other drug use, and Antabuse works to prevent alcohol use, but only if people take it.

Just 'one part of the treatment whole'
Without attention to addiction as a multifaceted, biopsychosocial illness with physical, psychological, social, and spiritual consequences, I'm afraid we will see limited benefits from this new attempt to treat opiate addicts. It should be successful, as methadone, in harm reduction and in limiting some of the significant medical, social, and legal problems associated with opiate dependence.

However, medication alone is not the answer, nor is it recovery. It's my hope that physicians committed to addiction treatment will use buprenorphine as one part of the treatment whole when addressing opiate addiction. Nonetheless, I'm afraid that the constraints of primary care medical practice, and the difficulties presented by opiate addicts, will limit attempts to provide comprehensive addiction treatment and undermine the potential of this new medication and the possibility of recovery for many opiate addicts.

Published in The Voice, Winter 2003