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Tapering Buprenorphine: Go Slow

Summary and Comment |
November 7, 2013

Tapering Buprenorphine: Go Slow

  1. Steven Dubovsky, MD

For patients with addiction to prescription opioids, a 4-week taper from buprenorphine was more effective than shorter tapers.

  1. Steven Dubovsky, MD

Buprenorphine and buprenorphine/naloxone (Suboxone) play major roles in detoxification from prescription opioids (as well as illicit narcotic addiction) and maintenance of abstinence. To determine the optimal detoxification protocol, researchers enrolled 70 employed patients (mean age, 28; 94% white) who were primarily dependent on prescription opioids (mostly oxycodone) for 5 years, lacked major psychiatric comorbidity, and wanted detoxification. Participants were stabilized on manufacturer-supplied buprenorphine/naloxone and then randomized to behavior therapy plus a double-blind 1-, 2-, or 4-week taper of buprenorphine followed by maintenance therapy with naltrexone. Mean length of stabilization was 2 weeks.

The 4-week taper was superior to the shorter tapers, with 50% of patients in that group remaining in treatment, abstinent, and receiving naltrexone after 12 weeks, versus 21% for the other groups. Patients who required 8 mg or more of buprenorphine for stabilization were only one fourth as likely as those needing lower dosages to have a favorable outcome.

Comment

Because of federal regulations, buprenorphine and buprenorphine/naloxone are more readily available than methadone for the treatment of narcotic dependence, and they are more frequently used for patients with the less complicated addictions to prescription opioids. Still, only 50% of patients who were motivated to stop taking the narcotic and to be maintained with a narcotic antagonist did well for just 3 months after the longest taper. In view of this and of other data reporting much lower rates of abstinence and treatment retention after buprenorphine withdrawal, there may exist a larger group of patients, especially those with comorbid psychiatric disorders, who require longer stabilization, extended tapers, and prolonged maintenance.

  • Disclosures for Steven Dubovsky, MD at time of publication Grant / research support Amgen; Janssen; Otsuka; Sunovion; Takeda Editorial boards Bulletin of the Menninger Clinic; Current Psychiatry; Journal of Psychosomatic Research

Citation(s):

Reader Comments (4)

Walter McLean MD Physician, Allergy/Immunology, Gosnold Treatment Center Falmouth MA

Unless the recovering addict is enrolled in continuing counseling and ESPECIALLY a 12 step program then he is certain to relapse in spite of any Suboxone taper. I believe that motivation for abstinence is th key to recovery not medication.

LOU LAFOND Family Medicine/General Practice

Excellent review of buprenorphine and its benefit withsome patients

Robert S Wilson D.O.,ASAM, ABAM Physician, Other, INPATIENT CD TREATMENT

After 100's of detoxes I have found lower doses than recommended by the manufacturer are best. My average dose is 12mg/day with a few on only 2mg/day.I wonder what your average dose was in this study.

Max Carter, PA-C, PhD Other Healthcare Professional, Palliative Medicine, Private Clinic

As a 20 yr veteran in the pain arena, I do not agree with the comment that Suboxone and Subutex are more readily available than methadone. The cost of the former is more than the average patient can afford, even with insurance, and as providers with a license to prescribe it, they can only have 100 patients on it at any one time!!!!!!!!!!!! Methadone is dirt cheap and more readily available from pharmacies, hands down. Any patient, especially the young, who want to detox can't afford the Suboxone or Subutex at $400 - $600 per month, especially if they do not have insurance. And even if they can, it is often short-lived because of cost. The FDA clearly has it backwards, limiting Suboxone to 100 pts at a time per provider, but not giving a rats rear about how much methadone can be prescribed. How many pts have you had overdose on Suboxone vs. methadone? None, because they can't do it! The FDA is a joke and clearly in bed with the pharmaceutical companies and don't give a rat's rear how many of our young people OD and die. I've lost two pts this year for the simple reason they couldn't afford Suboxone so the only alternative I had was to place them on methadone for detox and the result was devastating. I'm still fighting a case because of one of these cases where the patient couldn't afford to continue on Suboxone, but instead asked to detox on methadone. He elected to commit suicide on the methadone and the parents filed a formal complaint with the state board saying I murdered their son! It is a no win situation for those of us on the front line trying to help those who want to be drug free.

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