Frequently Asked Questions

The Drug Abuse Treatment Act of 2000 (DATA-2000) was written to allow for a variety of new drugs to be used in an office based setting by certified physicians. One aspect of this Act is the limitation of 30-100 patients per physician. In 2002 Suboxone®/Subutex® became the first drugs that physicians could use and as of now buprenorphine preparations are still the only approved medications. Without knowing the abuse potential or other social impact of these yet to be discovered drugs for addiction safeguards were built in the law. Many patients and physicians have complained that the law is too restrictive because almost every physician can prescribe potentially addictive medication, but once a patient becomes addicted, physicians are restricted on how many they can treat for addiction.

The law has been amended twice. The first in August 2005 allowed every certified doctor to prescribe to up to 30 patients regardless of whether they are in a group or sole practice. The second amendment was signed into law 12/29/2006 and allowed physicians who have had their DATA-2000 certification for more than one year the option of increasing their maximum to 100 patients. This change had a great impact on the number of patients that could get treatment.

Precipitated withdrawal can occur when an antagonist (or partial antagonist, such as buprenorphine) is administered to a patient dependent on full agonist opioids (e.g. Oxycontin®, methadone, heroin). Due to buprenorphine’s high affinity but low intrinsic activity at the mu receptor, the partial antagonist displaces agonist opioids from the mu receptors, without activating the receptor to an equivalent degree, resulting in a net decrease in agonist effect, thus precipitating a withdrawal syndrome.

It is a common misconception that the naloxone in suboxone® initiates precipitated withdrawal. This is false. The naloxone can only initiate precipitated withdrawal if injected into a person tolerant to opioids. Taken sublingually the Naloxone has virtually no effect.

How to avoid precipitated withdrawal: The best way to avoid this condition is through patient education. The patient should be informed, prior to the induction appointment, of discontinuing opioid use and to administer buprenorphine when withdrawal symptoms are present.

How to Treat Precipitated Withdrawal: If the patient experiences precipitated withdrawal, administer additional 2mg. to 4 mg. doses of buprenorphine hourly, until symptoms dissipate.

No– With successful buprenorphine detoxification and counseling the patient can put the addictive behavior in remission. At Arya Hospital Neuropsychiatry & Trauma Centre, buprenorphine is only used short-term (7 -28 days) for withdrawal. The dose of buprenorphine is reduced over time and eventually discontinued during this period. Physical dependence is unlikely to be established during this short term use of buprenorphine.

You will still be able to be treated for pain with elective dental or surgical procedures. Your doctors should speak with each other about the plan. They will likely stop your buprenorphine medication, at least 36 hours before the procedure, and then when you are ready to go back on buprenorphine you will need to be re-induced, which means stopping your pain medicine, experiencing mild withdrawal (for a very short time) and restarting your buprenorphine.

It is recommended to take the first day of treatment off. Some are able to work even on Day One. Certainly after Day One, you should be able to work with greater attentiveness and clarity than before starting treatment. The transition from addictive substance to buprenorphine is usually painless and most patients experience no adverse physical effects. In fact most say that they feel normal again, like they were never on drugs at all.

We never know what could happen. What if there is an emergency and you need to be treated for pain? Worse yet what if you are unconscious? A potential problem is you could be unnecessarily under-treated for pain. Since many doctors out there are still unfamiliar with buprenorphine, Arya Hospital Neuropsychiatry & Trauma Centre will provide you with a buprenorphine card that lists the name and phone number of the prescribing doctor and a patient information brochure. Keep this in a wallet or folder just in case of emergency. Hopefully it will never be needed.

It is best to SLOWLY reduce your therapeutic dose of Methadone to 30 mg a day or less for at least a week, before discontinuing it completely for at least 36 hours before starting buprenorphine. You MUST be in mild to moderate withdrawal before you take your first dose of buprenorphine. If you are doing well in Methadone treatment it may not be advisable to change treatments at all unless you and your doctor determine it is in your best interest. It is VERY important to follow these guidelines and prevent precipitated withdrawal.

Your physician will be able to determine what medications can be safely prescribed with buprenorphine. Generally psychotropic medications such as antidepressants can be combined with buprenorphine, as are most medications to treat hypertension or diabetes. However there are certain medications that have to be avoided or used with extreme caution with buprenorphine. Benzodiazepines (Xanax®, Klonopin®, Valium®) carry a particular risk of overdose when combined with buprenorphine and are generally avoided. Similarly sedative-hypnotic medications like Ambien® and prescription opioids like Perocoet® and Vicodin® are generally avoided with buprenorphine.

Many people use drugs because they are knowingly or unknowingly self-medicating for an underlying psychiatric condition. In either case, once the addiction is being treated the psychiatric condition will surface and require treatment. This patient would be well served by getting buprenorphine treatment through an addiction psychiatrist or a psychiatrist who specializes in the illness with which the patient is afflicted. At Arya Hospital Neuropsychiatry & Trauma Centre, you will receive a comprehensive medical assessment to determine if you have any co-occurring psychiatric or medical conditions. If the conditions are stable, buprenorphine can be generally prescribed. However the final determination can be made only after a medical assessment. Unstable psychiatric (e.g. suicidal patient) or medical conditions (e.g. kidney failure) are contraindications for buprenorphine.

When swallowed, some people have reported nausea. The naloxone and the buprenorphine are not absorbed well in the stomach. Although some medication will get into the bloodstream (about 20%) it is not an efficient method, and the effect is like taking one fifth of the medication. Therefore, much of the medication is, in effect, wasted.

The Food and Drug Administration (FDA) has approved injectable buprenorphine to treat pain, and for peri-operative analgesia. Buprenorphine is a powerful analgesic, 20-50 times more powerful than morphine, with less physical dependence. Buprenorphine has also been reported to relieve refractory depression in some cases, but this particular use has never been approved by FDA.
FDA has approved buprenorphine (Subutex®) and buprenorphine/naloxone (Suboxone®) to treat opioid dependence. However, neither Suboxone® nor Subutex® has been approved by the FDA for the treatment of depression or pain. Thus any use of Suboxone® and Subutex® for pain or depression is considered an off-label, unapproved use of these medications. Arya Hospital Neuropsychiatry & Trauma Centre does not prescribe any buprenorphine preparations for off-label uses such as pain and depression.

Physical connections create pathways in the brain that can be altered when we learn something new. These changes to the brain can be seen with medical imagery. Addiction is a learned behavior that changes the brain as well. The brain becomes conditioned to want the substance. Through counseling and other behavioral modification we can actually, in some cases, change the brain physically. By changing our environment, starting a new job, new hobbies and friends, all will alter our brain in some way. It is possible to undo some of the changes that occurred while addicted. Therapy will recondition the brain closer to pre-addiction status. This will better prepare the patient for a time when they may no longer require medication.
Medication alone can reduce cravings and withdrawal, but recovering from an addictive disorder requires a rewiring of the brain and medication alone is not enough. Attention to eliminating things in life that cause stress or depression will help minimize the chance of relapse. Disassociating with friends who are in active addiction can be difficult but very necessary. An experienced counselor/therapist will be able to teach other techniques that will further help undo some of the brain changes and conditioned learning that occurred while becoming and remaining addicted.

Opioids attach to receptors in the brain, with three main effects; reduced respiration, euphoria, decreased pain. The more opioids ingested the more of an effect. The process of opioids binding to the opioid receptors can be thought of as a mechanical union, the better the fit the more the opioid effect.

Buprenorphine is different. It too binds to the receptors, however, without a perfect fit. As a result the buprenorphine tends to occupy the receptors without all of the opioid effects. The receptor is tricked into thinking it has been satisfied with opioids without producing the feeling of euphoria, and without causing respiratory depression. This, in turn, prevents that receptor from joining with full opioids; therefore if the patient uses heroin or painkillers, they will not be able to experience any additional effect. Buprenorphine tends to stay with the receptors, blocking them, much longer then opioids do. This stickiness, is what makes buprenorphine last so long, up to 3 days.