People frequently seek my help in finding an addiction treatment facility for themselves or a loved one. And just recently, a family sought my assistance in locating residential treatment for their opioid-addicted young adult son. One facility after another told me they don’t use or recommend “maintenance” use of buprenorphine – which most people know as Suboxone – aside from using it during detox, to make withdrawal a more comfortable experience.
Yet many research studies show that maintenance or long-term use of Suboxone (prescribed by specially certified physicians) or methadone (dispensed by special clinics that must be visited daily) not only helps individuals remain free from addiction to such opioids as prescription painkillers and heroin, it lowers death rates and prevents complications of addiction such as infections. The National Institute on Drug Abuse provides background information on these medications and how they work, as does the Substance Abuse and Mental Health Administration (SAMHSA).
Here are some of the responses I received from representatives of the rehabs I recently queried about whether they use or recommend Suboxone past the detox phase of treatment:
- “Short answer, no. Suboxone is a temporary solution for a permanent problem.”
- “You can get strung out on Suboxone as badly as on heroin.”
- “Oh no, absolutely not. We do not discharge them on Suboxone.” When I mentioned that the scientific literature reports that people do better on maintenance Suboxone than not, I was told, “The scientific literature is false. I’ve been doing this for 20 years.”
- “We’re abstinence-based. Our success is getting to the underlying issues and we can’t get to those when they’re under the influence of a narcotic or other medications.”
Technically, Suboxone and methadone are opioid medications, and opioids are sometimes called narcotics. (Suboxone is a combination of buprenorphine and the medication, naloxone, which is added to decrease its potential for misuse.) Both block cravings and drug seeking – they do not produce a high or impair functioning when properly prescribed.
The notion that these are ‘narcotics’ that prevent people from doing intensive therapy when used properly is ridiculous; the converse is true.-Dr. Mark Willenbring
If someone treated with them uses an opioid such as heroin, the euphoric effects are usually dampened or suppressed. “The notion that these are ‘narcotics’ that prevent people from doing intensive therapy when used properly is ridiculous; the converse is true.” says Mark Willenbring, M.D., founder and CEO of Alltyr treatment clinic and former Director of the Division of Treatment and Recovery Research of the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health (NIH). To achieve stable recovery, some people need to stay on these medications for long periods of time, sometimes indefinitely.
Another less commonly used medication for maintenance treatment is naltrexone, available in pill-form or as an extended-release monthly injection marketed as Vivitrol. Naltrexone blocks the opioid receptors and prevents any effect of opioid drugs such as heroin or prescription opioids.
Why the Resistance to Suboxone?
I posed this question and many more to the University of Washington’s Andrew J. Saxon, M.D., an addiction psychiatrist with decades of clinical, research, and training experience in the area of opioid use disorders. When I told him about my difficulties with trying to find a rehab that supported Suboxone maintenance treatment, he said, “I get so frustrated with these inpatient programs that are wasting people’s time and money and exposing them to risk of overdose.”
He was referring to the fact that patients who get discharged without being placed on Suboxone or referred to Suboxone prescribers or methadone clinics are highly likely to experience drug cravings, then use again. They risk overdose because if they return to their pre-treatment levels of drug use after being abstinent in rehab, their bodies won’t be able to handle drug levels that high.
Following are Dr. Saxon’s responses to my questions about the resistance to maintenance use of Suboxone:
- Why do you think so many treatment providers continue to be so resistant to Suboxone (and methadone) maintenance treatment of opioid use disorders?
Dr. Saxon: Of course it is only speculation, but one obvious answer is that residential/inpatient programs have a financial incentive to detox people and tell them that recovery without medication-assisted treatment is better. If a patient is choosing to go on methadone or Suboxone, inpatient treatment is unnecessary in the vast majority of cases. Also, many of the staff in these programs are recovering from alcohol use disorders (AUDs). They simply do not understand that opioid use disorders (OUDs) are substantially different, though of course there are some commonalities.
Another reason for resistance is fear of Suboxone “diversion” – when it’s abused or not used as prescribed or given or sold to other people. Studies suggest that most diversion occurs when people addicted to opioids are trying to get off them and don’t have medical access to Suboxone. It is very rare in the U.S. for people to use Subxone in an attempt to get high.
- How are OUDs substantially different than AUDs?
Dr. Saxon: Opioids affect the brain (and the body—because we have opioid receptors on our smooth muscle and our gut) differently than alcohol. So the substance effects, the intoxication, the withdrawal and the ultimate changes that occur long term in brain and body after years of exposure are bound to be different. Fully explicating the differences on a cellular or molecular level is probably a Nobel Prize-winning endeavor! But it all means that treatment needs are not just the same as for AUDs.
- Is there any evidence that residential treatment is valuable for OUDs?
Dr. Saxon: There is no evidence that I know of for the standard 28-day programs, and we do know that risk of overdose is high after leaving one of those programs if patients are not continued on Suboxone or methadone. There is evidence for therapeutic communities – residential facilities where patients stay six months or longer. Of course, such programs are few and far between.
- The CEO (also an addiction psychiatrist) of a company that owns a group of prominent rehabs directed me to a large Australian study, pointing out that one-year outcomes showed that medication maintenance treatment and residential treatment were equally effective. Why do we seldom hear about this study?
Dr. Saxon: One cannot generalize from Australia to the U.S. – they have a very different health care system than we do. Also, there were multiple problems with the study design – for instance, it was not randomized, and the researchers don’t even report if there were baseline differences between the groups. And all outcome data were based totally on self-report so we have no objective findings.
- It’s often stressed that whenever maintenance medications are prescribed for OUDs, counseling is also important. But haven’t a number of recent studies shown that counseling confers no added benefit to the medication alone?
Dr. Saxon: Such studies relate specifically to office-based treatment with Suboxone and not to methadone maintenance. The findings are consistent in showing that outcomes were not improved when either drug counseling or cognitive-behavioral therapy were added to use of Suboxone and medical management alone. So in early treatment, it is the medication (Suboxone) that is causing the majority of change. Keep in mind that these studies only look at patients in the first several months of treatment, so we really don’t know the effects of behavioral interventions later on.
Moreover, it’s important to realize that the physicians prescribing the medication in these studies received training on how to do gold standard medical management which includes important behavioral components. So the real message is that if you have a caring and competent physician prescribing buprenorphine who asks the right questions and makes the needed suggestions, adding on more behavioral interventions may not make a huge difference. All physicians out in practice may not have these skills, though they are not difficult to learn. In methadone treatment it is pretty clear that the medication plus standard drug counseling is better than simply giving medication alone.
- What if people with OUDs have co-occurring psychiatric problems? I would think this is a big exception to the “no counseling benefit” finding, one that impacts many individuals.
Dr. Saxon: Very good point, and we don’t fully know the answer because individuals with severe psychiatric disorders are mostly screened out of such studies (many in the studies might have mild to moderate psych disorders.) However, patients with psychiatric disorders need psychotherapy and/or pharmacotherapy directed at their psychiatric disorders, not more behavioral interventions that address their addiction per se.
- Some rehabs prefer Vivitrol to Suboxone, arguing that “head-to-head,” they are equally effective. Is this true?
Dr. Saxon: Actually, there is far more evidence supporting the efficacy of Suboxone (and methadone) than injectable naltrexone or (Vivitrol). Only one clinical trial done in Russia (which does not permit Suboxone or methadone) supports injectable naltrexone, and that’s the one on which the Food and Drug made its decision to approve Vivitrol for OUDs. Right now, an ongoing study funded by the National Drug Abuse Treatment Clinical Trials Network is comparing the effectiveness of Suboxone versus Vivitrol for OUDs. Using naltrexone does require withdrawal off opioids for about a week before starting it, so it is more complicated in that way than using the other maintenance medications. However, if someone can make it through the withdrawal and wants to try Vivitrol, I wouldn’t have any qualms about it but would monitor the person carefully and be quick to switch to Suboxone if the person isn’t doing well. (The risk of overdose may be higher with naltrexone than with Suboxone or methadone if clients drop out or stop medications, but it’s a risk with any of the medications, and all patients should be warned.)
- The CEO of the rehabs defended not using Suboxone at their “abstinence-based facilities,” by saying that their patients will be going to AA and NA in the community and that 12-step programs don’t see Suboxone and methadone users as abstinent, even though the medical world does. He said, “We don’t control how the recovery community sees the world. So our big focus has been on Vivitrol.”
Dr. Saxon: So their reasoning is that the AA groups are not following the actual precepts and stated policy of AA, which is to accept people who are on medications prescribed by physicians? And the rehab program is not doing the medically correct thing so as to make their patients fit into AA groups that are running AA incorrectly and judging people? They should be out there trying to get AA groups to practice AA the right way. However, if they can get Vivitrol to work, wonderful, I’m all for it.
- How do costs compare between the various forms of maintenance treatment, and how likely is insurance to cover them?
Dr. Saxon: Methadone costs between $300-400 per month, which includes medication, medication dispensing, medical evaluation, counseling, and urine testing. Suboxone medication cost would be about $300-400 per month retail. Physician and counseling fees would be additional. Vivitrol is about $1000 per dose with one dose per month. Physician and counseling fees would be additional. Medicaid covers all these treatments in many states but exact coverage varies from state to state. Private insurance often covers them (variations from policy to policy, obviously), but what I hear from physicians in private practice is that it is a huge hassle to get prior authorization at times.*
- Finally, the rehab CEO expressed concern that with Suboxone, about 60 percent of people drop out of treatment by the end of six months, and we need to be concerned. What do you think about this?
Dr. Saxon: I agree. I will have a commentary coming out in the journal Addiction this year, which makes the very same point. We need to improve our retention rates dramatically. However, saying that one treatment is suboptimal does not mean the other treatment (rehab) is necessarily better.
Let me also just say that I am not against rehab. I have just had too many calls from families whose loved ones have gone through rehab many times and continue to use opioids. Rehab alone probably works for some, but when it doesn’t, we need to be quick to try medication.
Related Reading: The Buprenorphine Diversion Problem
Image Credits: Suboxone photo courtesy of naabt.org