By London, Robert T.
Clinical Psychiatry News , Vol. 33, No. 5
Recently I attended a continuing medical education program at Columbia University's College of Physicians and Surgeons.
The program focused on the use of the partial opioid agonist buprenorphine for treating opioid dependence in an office practice. Our focus was on a formulation called Suboxone, which combines buprenorphine and naloxone. Suboxone is the preferred formulation of buprenorphine for maintenance treatment.
My special interest in the treatment of addiction has focused on tobacco smoking, which I believe is our greatest health hazard ("A Twist on Dual Diagnosis," CLINICAL PSYCHIATRY NEWS, January 2005, p. 30). So I was fascinated to learn about some of the progress we have made in treating opioid dependence.
The use of medication for addiction treatment is not new. For example, disulfiram (Antabuse), bupropion (Wellbutrin, Zyban), nicotine patches, and nicotine gum all have their place in addiction medicine.
The use of methadone--the first recognized chemical treatment for opioid addiction and dependence in the United States--began in the early 1960s.
Over the past 40 years or so, the concept of methadone maintenance has been controversial. Many people believe that "drug free" is the only way to treat addiction. That notion holds merit, and I'm certain that many people who are on maintenance programs would share that view.
But according to Eric D. Collins, M.D., a psychiatrist at Columbia University and one of the faculty members teaching this program, "When a patient regularly demonstrates that opioid dependence cannot be controlled through abstinence and that continued use presents a high risk of disease transmission, institutionalization, incarceration, and/or death, it's time to work within medical boundaries to treat opioid addiction in the best way we can."
This rationale supports the use of maintenance treatment with methadone--and now, to add another alternative in certain circumstances, buprenorphine. Because the use of buprenorphine is sufficiently complicated and the drug is prone to diversion, an 8-hour course and a Drug Enforcement Administration certificate is necessary to treat with buprenorphine in office practice.
Dr. Collins, a strong believer in the utility of buprenorphine for opioid dependence, sees this treatment not as a replacement for methadone, but as a parallel treatment for certain levels of opioid addiction. He points out that buprenorphine transitions patients from their illicit opioid use to buprenorphine. The program accepts people only after careful psychiatric/psychological evaluation of opioid use.
Furthermore, a personality inventory is taken, support systems are evaluated, and counseling or psychotherapy is offered for patients entering a buprenorphine maintenance program. Dr. Collins and clinical psychologist Margaret Rombone, Ph.D., work diligently to take psychiatric and psychological aspects of the people in the program as seriously as the actual use of medication in the program. The early stage--especially the first week--of buprenorphine treatment generally requires more intensive treatment. After that, the process usually goes smoothly, as long as relapse doesn't occur. …