Information regarding buprenorphine (suboxone, subutex) for narcotic dependence

Buprenorphine (suboxone) is FDA approved in the US only for narcotic dependent patients and requires special training and a second DEA number to prescribe. In Europe it is also used for chronic pain and is a moderate pain medicine with partial agonist action at the narcotic receptors.

Narcotic dependence can include patients who are using heroin, using prescription medicines illegally or obtaining them through lying, or patients with chronic pain, present or resolving, who have also gotten hooked on narcotics and are overusing or abusing them.

Buprenorphine is tricky to START patients on because it is a partial agonist but sticks to the receptor like glue. So it can kick out any other narcotic including methadone, heroin, oxycontin, all of them out of the receptor. So to START it, the person has to be in withdrawal and that is called an induction. This is why it requires the special training and DEA number. If a patient is not in withdrawal, and is taking a much higher dose of heroin, oxycontin, methadone or other narcotics, they can get immediately massively sick.

Once a patient is on the buprenorphine, it works well for addiction. If they are on the combined buprenorphine/nalaxone, they can't abuse it because the nalaxone stops them from injecting it iv. It doesn't work swallowed. It has to be absorbed slowly under the tongue. It is a partial agonist so it gives moderate pain relief, but it blocks all of the other narcotics, so it is great for addiction and has a very long half life. Some people can take it only three times a week. It doesn't make people somnolent, and the chance of overdose and death are very small. The chance is much higher if you add in benzodiazepines or alcohol.

The DEA said that to use it for addiction I have to prescribe with my second DEA number, which starts with an X. To use it for chronic pain, that is off label and not FDA approved in the US, though it is used for both chronic pain and addiction in Europe. It is much safer than methadone. To use it for chronic pain, the DEA said use the regular DEA number and put "chronic pain" on the script and chart why it's being used. The DEA said that providers can use it off label as long as they use the DEA numbers correctly. Ethically, I think that it is way safer to keep a chronic pain patient that is doing well on suboxone/nalaxone on that than to switch them to long or short acting other narcotics. For the first year after training, a provider can have a maximum of thirty patients maintained on suboxone.

The suboxone/nalaxone used to be much more expensive than the suboxone alone. Suboxone alone can be abused by using it injected. A cheaper suboxone/naltraxone film, rather than tablet, just came out and the pharmacies have it.

I am working with the UW Pain Clinic through the Roam-Echo program, which means that we have an on-line conference every two weeks, with a team including an addiction specialist, chronic pain specialist and psychiatry. The UW Pain Clinic will not accept patients on benzodiazepines in the suboxone program; they must wean first. That and alcohol are causes for consideration of removal from the program because of the risk of overdose and death. Other suboxone provider clinics may have different rules, much as the methadone clinics have different boundaries about alcohol and drugs than the chronic pain clinics.

There is more information at the Substance Abuse and Mental Health Services Administration (SAMSHA) and buprenorphine prescribers can be found on a voluntary list on the SAMHSA site. There are also listings of inpatient treatment centers that can continue buprenorphine and sites for dual diagnosis patients, meaning those with mental health and drug addiction problems.