Buprenorphine is the first major medication approved for the treatment of opioid addiction in almost 20 years. In terms of efficacy and convenience, it has several major advantages over the existing medications, methadone and naltrexone.

The NIDA Research Report on Heroin Abuse and Addiction notes that buprenorphine "causes weaker opiate effects and is less likely to cause overdose problems. Buprenorphine also produces a lower level of physical dependence, so patients who discontinue the medication generally have fewer withdrawal symptoms than do those who stop taking methadone. Because of these advantages, buprenorphine may be appropriate for use in a wider variety of treatment settings than the currently available medications."

Suboxone, a buprenorphine formulation that includes the opiate antagonist naloxone, has been approved for use in office-based treatment – a take-home medication that has the potential to reach far more opiate addicts than methadone. Amid the excitement and euphoria on the availability of this new treatment modality, however, we need to be aware of a disturbing trend that could besmirch this medication and send it the way so many other medications of the past.

The early warning signs of buprenorphine misuse and abuse are trickling in, and appropriate countermeasures need to be taken before the problem escalates out of control. At our clinic, for example, we have encountered patients:

• wanting only a script for Suboxone and refusing counseling
• insisting that they need the maximum dose to feel well
• bartering/selling/giving the buprenorphine to other addicts
• testing positive for opioids or refusing urine screens
• 'losing' their scrips and asking for a new scrip
• using buprenorphine intermittently to sustain heroin use
• resisting attempts to taper down the dose and getting off the medication
• doctor-shopping

These troubling developments have made some physicians take their names off the buprenorphine locator, and caused others to decide against being listed. It may potentially slow down the efforts to get more physicians trained on the use of buprenorphine.

Buprenorphine is still in the relatively early stages of widespread use, and physicians and patients may not have complete information on the pharmacology and formulation of Suboxone. Indeed, we have observed some highly inaccurate and misleading information circulating as fact, such as:

• Naloxone prevents the medication from being abused (Fact: Naloxone offers no protection if patients attempt to use benzodiazepines, alcohol and other tranquilizers while taking Suboxone);
  
  
• Buprenorphine has a 'ceiling' effect on the 'high' and therefore is non-addicting (Fact: The 'ceiling' effect is seen markedly on respiratory depression and not with the abuse.)
  
  
• Buprenorphine use can be stopped immediately (Fact: Buprenorphine is a Scheduled III drug and chronic use produces dependence similar to other opioids but milder. To avoid withdrawal symptoms, gradual tapering is recommended.)

If we in the treatment community are not vigilant, there is a very real danger that more restrictions may be imposed by authorities like the International Narcotics Control Board on the use of buprenorphine, depriving us of an effective tool in the treatment of heroin addiction. Let us learn from the past mistakes and make sure that this valuable medication does not become a street drug and add to the stigma associated with addiction.

The annals of our field are littered with sure-fire cures that ended doing more harm than good. Benzodiazepines and LSD were once used to treat alcoholism, as was laudanum, which contained high concentrations of morphine; heroin was used to treat morphine addiction; and the list goes on. The indiscriminate use of highly addicting drugs resulted not only in the rejection of medications to treat addictions and alcoholism, but an enduring distrust of science and the medical community which still exists today.

At the very least, patients should be asked if they are attending self-help groups or other relapse counseling groups; random urine screens should be collected to check if patients are using heroin or other illegal opioids; counselors should spend time with patients to check the veracity of their stories; and programs should exercise a little more caution regarding Suboxone dosage. 

Most physicians in addiction medicine have considerable experience is dealing with manipulative patients. An extra dose of caution in prescribing the medication would go a long way toward keeping restrictions on buprenorphine to a minimum.

Editor's Note:
Percy Menzies, M. Pharm., is the president of Assisted Recovery Centers of America, a St. Louis-based treatment center for alcohol and drug use disorders. He can be reached at: percymenzies@arcamidwest.com.