The confidentiality of alcohol and drug dependence patient records maintained by Alpha Healing Center are protected by federal and state law and regulations. Generally, the program may not say to a person outside the program that a patient attends the practice/program, or disclose any information identifying a patient as being alcohol or drug dependent unless:
Violation of the federal law and regulations by a practice/program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/program or against any person who works for the practice/program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.
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.
Any physician with a special “X” number issued by the DEA. The way the law is written, any doctor can prescribe Suboxone® for treating pain, however the FDA has not granted approval for Suboxone® to be used for pain, so it would be an off-label prescription. There are other restrictions for those who want to prescribe it for opioid addiction treatment (what the FDA approved it for). Doctors must take an 8-hour class on addiction treatment, or already possess such credentials, and then apply for a special DEA#. Alpha Healing Center physicians are trained and licensed to prescribe Suboxone®.
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 Alpha Healing Center, 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, Alpha Healing Center 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 Alpha Healing Center, 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.
If you miss a dose and remember it a few hours later, take it upon remembering. If you forget until it is close to the time of the next day’s dose, do not take a double dose. Not because you will take too much but rather you will just be wasting it, due to the ceiling effect. After being on treatment for a relatively short period of time you will feel so normal it may be difficult to remember unless you tie taking your medication to an activity you do every day at the same time. For example, after you have coffee or orange juice in the morning, or while reading the newspaper.
Most insurance companies cover the medication itself with different copays. Some insurance plans require preauthorization or mandate the type of buprenorphine formulation that is covered. Individuals who have no insurance, or a high deductible or prefer not to use insurance have to pay out of pocket for the medication. Alpha Healing Center will check whether your insurance plan covers Suboxone® and will obtain the preauthorization for prescribing the medication. You will have to pay the necessary copayment for the medication.
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. Alpha Healing Center 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.
This is an important concept. It is why buprenorphine is unique as a treatment medication.
An agonist is a drug that activates certain receptors in the brain. Full agonist opioids activate the opioid receptors in the brain fully resulting in the full opioid effect. Examples of full agonists are heroin, oxycodone, methadone, hydrocodone, morphine, opium and others.
An antagonist is a drug that blocks opioids by attaching to the opioid receptors without activating them. Antagonists cause no opioid effect and block full agonist opioids. Examples are naltrexone and naloxone. Naloxone is sometimes used to reverse a heroin overdose.
Buprenorphine is an opioid partial agonist. This means that, although buprenorphine is an opioid, and thus can produce typical opioid effects and side effects such as euphoria and respiratory depression, its maximal effects are less than those of full agonists like heroin and methadone. At low doses buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to stop the misuse of opioids without experiencing withdrawal symptoms. The agonist effects of buprenorphine increase with increasing doses of the drug until it reaches a plateau and no longer continues to increase with further increases in dosage. This is called the “ceiling effect.” Thus, buprenorphine carries a lower risk of abuse, addiction, and side effects compared to full opioid agonists. In fact, buprenorphine can actually block the effects of full opioid agonists and can precipitate withdrawal symptoms if administered to an opioid-addicted individual while a full agonist is in the bloodstream. This is the result of the high affinity buprenorphine has on the opioid receptors. The affinity refers to the strength of attraction and likelihood of a substance to bind with the opioid receptors. Buprenorphine has a higher affinity than other opioids and as such will compete for the receptor and win. It will “knock off” other opioids and occupy that receptor blocking other opioids from attaching to it. If you try to take opioids on top of buprenorphine, you will experience no effect.
Like any other treatment, you should receive medication only as long as it is needed and is effective in treating the disease. For purpose of detoxification, this ranges from 3 days to 28 days to manage your withdrawal and craving. However detoxification is not the end of treatment. Even if you are not taking Suboxone®, you should continue to participate in psychosocial counseling.
Certain opioid dependent individuals need and desire long-term treatment with Suboxone®. This could be months, years or indefinitely. This is called maintenance treatment. You and your healthcare team will determine what is best for you, based on any side effects, history, environment and many other factors. Although considered to be the most significant new treatment for opioid dependence in 30 years, buprenorphine alone is not a cure. It can only be effective with a complete treatment plan including appropriate behavioral therapy and monitoring. Alpha Healing Center does not offer Suboxone® maintenance.
Suboxone® or Subutex® can be used for opioid detoxification treatment. Who requires opioid detoxification is determined by an evaluation by a Certified Physician and criteria for opioid detoxification established by national societies and state and federal regulatory agencies. It can be done in an office based setting (ambulatory or outpatient) or in a hospital/residential setting (inpatient detoxification). Alpha Healing Center provides Ambulatory Opioid Detoxification.
During the detoxification process, the opioid the patient is using is discontinued and Suboxone® or Subutex® is started. The dose and duration of treatment is decided by the physician-established protocols, but generally the Suboxone® is tapered within 7 days to 28 days.
Treatment with Suboxone® or Subutex® is not appropriate for everyone with opioid addiction. This determination can only be made after a thorough evaluation from a physician certified to use the medication.
Till Suboxone® became available a few years ago, the treatments available in a private doctor’s office for opiate addiction had significant limitations. Most people were unable to complete the detoxification process in an outpatient office. This meant that people would often need to go into a hospital setting and be detoxified with clonidine, methadone or other medications over a few days or longer. This process was very uncomfortable, required taking time off from work, being away from the family and the potentially high cost of the hospital stay if not covered by insurance.
Ongoing medication based treatment – to assist in keeping a patient off the opioids – was previously limited. The only option was to go to methadone clinics which are strictly regulated by State and federal agencies. Most patients are required to go every day to the clinic to get dosed by methadone imposing inconvenience and restrictions in personal life. Also methadone is chemically different from buprenorphine and produces greater tolerance, withdrawal and euphoria. This means often the methadone dose increases with time and withdrawal from methadone is protracted and uncomfortable.
Suboxone® is NOT a “magic pill” – but a key component of an overall integrated treatment approach that includes medication, counseling, monitoring and treatment of comorbid conditions.
Suboxone® not only helps with the initial detoxification but also helps to keep opioid addicted individuals off their drugs for extended periods of time – many times for good.
In October 2002 the FDA approved two prescription buprenorphine medications marketed as Suboxone® (buprenorphine/naloxone) and Subutex® (buprenorphine) available in 8mg. and 2mg. tablets or films. In addition, the FDA recently approved two more buprenorphine/naloxone formulations Zubsolv® and Bunavail® for treatment of opioid dependence.
Availability of Suboxone and Subutex has revolutionized the way opioid addiction can be treated. The medications work by allowing those addicted to opiates be weaned off the drug of abuse rapidly and with minimal discomfort. This is very helpful in detoxification treatment, because once you are stabilized on Suboxone®, it is much easier to withdraw it compared to typical opiates that are abused.
Suboxone® and Subutex® have been successful in treating addiction to all types of prescription opioids (Oxycontin®, Percocet®, Codeine, Vicodin®, and others) as well as heroin.
The medication is administered by placing a tablet or a film under the tongue (sublingual). Buprenorphine is absorbed through thin membranes into the blood vessels under the tongue within a few minutes. Bunavail® is a buccal film preparation that is administered by placing the film on the inner surface of cheek.
Subutex® contains only buprenorphine while Suboxone®, Zubsolv® and Bunavail® contain a combination of buprenorphine with naloxone. Naloxone is a medication that causes withdrawal in opioid dependent people. However, naloxone is poorly absorbed sublingually, or when taken orally. Therefore, taken as directed, very little naloxone enters into the blood and has no effect. The purpose for the addition of naloxone to buprenorphine is to reduce the risk of misuse. If Suboxone® is misused (administered intravenously), the naloxone will cause immediate and intense withdrawal in opioid-dependent people.
Suboxone® and Subutex® can only be prescribed by specially certified and licensed physicians with expertise in the treatment of addictions.
Buprenorphine is a semi-synthetic opioid derived from thebaine, an alkaloid of the poppy plant. Intramuscular preparations of buprenorphine have been used to treat pain for several years. Sublingual buprenorphine is a new medication approved by the FDA to treat opioid addiction in the privacy of a physician’s office. Buprenorphine can be prescribed by a certified physician and can be picked up from a local pharmacy. This, in addition to buprenorphine’s pharmacological and safety profile makes it an attractive treatment for patients addicted to opioids.
Buprenorphine is different from other opioids in that it is a partial opioid agonist. This property of buprenorphine may allow for;
At the appropriate dose buprenorphine treatment may: