Magazine article Addiction Professional

Respect, Not Coddling, for Buprenorphine Patients: A Physician in Recovery Sees Patients Soar with an Assist from Buprenorphine

Magazine article Addiction Professional

Respect, Not Coddling, for Buprenorphine Patients: A Physician in Recovery Sees Patients Soar with an Assist from Buprenorphine

Article excerpt

The opioid scourge continues unabated. People continue to die at a record rate in spite of ever-increasing news coverage of illicit drug use. How can this be?

While friends, family members and others not dependent upon drugs view the flood of information with appropriate alarm, active opioid users do not. They wonder about the newer, stronger street drugs, especially fentanyl, and what it must feel like to find some. Most are sure they will use it wisely. Most do not think they will die. Some do think they might, but are willing to risk it.

How do I know they think this way? I am recovering from opioid addiction (17-plus years), and the thought does not shock me. More importantly, there is a recurrent behavior that provides empirical evidence that impaired thinking pervades the drug-using community.

The promulgation and use of the first aid medication naloxone (Narcan) by healthcare providers, law enforcement and education institutions has offered a window into opioid use and attempts to treat it. Naloxone also is being given to many individuals with opioid addiction who leave various treatment settings for use should they relapse. Consequently, large numbers of patients who relapse are being given the drug, and most are arriving at emergency rooms alive rather than dead. Though this represents progress in initial survival, there is much more to the story.

One would think that these patients would be relieved to have cheated death and would be ready to start a serious attempt at beginning treatment. But this rarely describes the actual scenario. Although naloxone has allowed the patient's breathing to begin again and can help restore a viable blood pressure, the patient quickly awakens in full-blown opioid withdrawal. Under these circumstances, the patient will agree to most any follow-up plan, as long as it starts tomorrow. The immediate need to relieve the worst withdrawal the patient has yet endured becomes paramount in the patient's mind. The individual must use again, as soon as possible. He will leave, against advice if necessary, leaving loved ones and friends bewildered. Chances are, if he doesn't die, he will be back again.

In my capacity as medical director of Phoenix House in Rhode Island, I have seen scores of patients admitted for detoxification and treatment as they continue in their addiction. Many readily admit to having suffered multiple overdoses requiring naloxone reversal within a one-year period. They are aware they are lucky to be alive, and often offer no promises that it will not happen again.

Although the public is baffled by such behavior, we providers cannot be. Respecting the power of a disease that so often brings the patient to the edge of death mandates our attention and resolve to avoid being deceived by our patients.


It is in the milieu of an opioid treatment center that the patient has the best chance for success. The patient should be offered medication-assisted treatment options. They include: methadone maintenance clinics; naltrexone, orally or in the form of monthly Vivitrol injections; and buprenorphine-assisted recovery. Here I will discuss the latter, as I believe it has been proven to work best for the majority of opioid-dependent patients. This medication has several qualities that make it ideal for those patients who wish to stop using now.

Buprenorphine is a partial agonist (activator) of the mu (opioid) receptors in the brain. It is at these receptor sites where nearly all the damage caused by opioid addiction starts and develops. Here is where tolerance for the opioid occurs. Tolerance is a need to take more of the drug, in use over a shorter period, in order to achieve the same result as when it was first taken. It is also at these receptors where healing can begin quickly by employing the appropriate introduction of buprenorphine into a formally scheduled treatment program. …

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