Buprenorphine Treatment for Comorbid Opiate Use Disorder and Psychiatric Disorders in Adolescents and Young Adults: Pros and Cons
Jeffrey Deitz MD
Soon after the Drug Abuse Treatment Act of 2000, the FDA approved the medication buprenorphine to treat opiate dependency. An alternative to methadone maintenance, buprenorphine offers several advantages; first, cooperative, reliable patients can be properly dosed and maintained in doctors’ offices without the inconvenience and stigma of attending methadone clinics; second, because of its chemistry, buprenorphine has little of the cognitive impairment, gastrointestinal motility disturbance, sexual dysfunction so typical of opiates like morphine, methadone and hydrocodone; and third, once titrated properly, the dose of buprenorphine required to stop opiate-craving and prevent withdrawal does not escalate. For individuals whose lives have deteriorated into the nightmarish cycle of drug-seeking and illegal activities to fund their habit, buprenorphine presents a medical insurance-covered alternative to methadone, legally obtainable in the offices of certified doctors. The psychological space and freedom from the all-consuming preoccupation of procuring opiates allows buprenorphine-treated individuals to recover their lives. Although individual doctors can prescribe buprenorphine the Substance Abuse and Mental Health Services Administration (SAMSHA) recommends that buprenorphine be a component of a comprehensive treatment program which includes individual counseling and ongoing support for attaining and maintaining sobriety.
However, as critics of buprenorphine rightfully point out, it is critical to understand from the outset that buprenorphine most definitely is an opiate and continues the opiate habit. In order to prevent diversion of the medication through chemical extraction of the active molecule into an injectable form, the original manufacturer, Reckitt-Benckeiser, concocted an ingenious sublingual formulation which combined buprenorphine and naloxone, an opiate antagonist that reverses opiate activity immediately (precipitating acute opiate withdrawal when injected) which is not absorbed when placed under the tongue. Originally available in orange tablets under the brand name Suboxone, many other formulations of buprenorphine with and without naloxone are now available and covered by medical insurance prescription drug benefits.
Nowadays, as opposed to years ago when new patients were switched from their opiate(s) of abuse to buprenorphine-containing medication in doctors’ offices (a process called induction), many opiate abusers arrive self-induced with street acquired buprenorphine, which they use not to get high, rather to prevent withdrawal.
A major limitation of buprenorphine is that individuals with a daily habit of greater than 160-200 mgs of Oxycontin or oxycodone , 40 or more milligrams of methadone or twenty bundles of heroin, are not candidates for treatment or conversion until their opiate load is tapered below that critical threshold. Another complication is that buprenorphine induction must be delayed until patients are in moderate to severe opiate withdrawal because buprenorphine’s high affinity for the mu subtype of opiate receptors displaces opiates of abuse, paradoxically worsening withdrawal if it is administered too close to the time of last opiate ingestion.
Even though patients say they feel normal, it is important to understand that buprenorphine exerts a powerful pharmacological effect. By analogy to a door studded with keyholes, buprenorphine attaches to the mu subtype of opiate receptors in the brain and body very tightly—think of keys shorn off at the stem of locks—denying access of other opiate molecules that might open the lock. Abrupt withdrawal or too-rapid tapering of buprenorphine produces all thedebilitating opiate withdrawal symptoms: nausea, sweating, muscle spasms, flu-like symptoms, restless legs, insomnia, gastrointestinal upset, depression, anxiety, and mood lability.
Although it may feel like it to those caught in the vicious cycle of abuseàcravingàwithdrawalàrelapse, buprenorphine is most definitely not a wonder drug. Patients and families should not assume that buprenorphine treatment guarantees an easy taper a few months down the road, or that buprenorphine withdrawal is any different from any other opiate withdrawal. For reasons which remain to be clarified, the opiate receptor systems of vulnerable individuals, typically those who have used high doses of opiates for prolonged periods, do not reset themselves to their pre-opiate dependent state. Would that we could promise people with opiate dependency detoxification and relief from dependency; however, that’s not the way the medicine, or the body, works.
So here the controversy stands. Should a physician prescribe a medicine that continues the opiate habit in the service of giving his patient a chance to recover his life? Or should a physician insist on using buprenorphine as an interim solution and taper it as rapidly as possible, even if the withdrawal and likelihood of relapse (with often fatal consequences) threatens his patient’s function?
Skeptical at first because it seemed like substituting one opiate habit for another, it didn’t take long for this clinician to appreciate how many lives buprenorphine saves. It had long been appreciated that many, perhaps the majority, of individuals in 12-step programs had dual diagnosis substance use plus psychiatric disorders. The psychiatric literature is replete with studies of individuals who use alcohol and benzodiazepines to self-medicate panic and posttraumatic stress; bipolar patients who abuse cocaine and psychostimulants to maintain their ‘highs;” and sleep disordered patients habituated to zolpidem or barbiturates. What became apparent once I treated opiate-dependent teenagers and young adults with buprenorphine was how often they had stumbled into opiate dependency in an attempt to self-medicate depression, usually bipolar depression.
Fanned by its introduction into the medicine chests of mainstream America in the mid 1990’s, Oxycontin found its way into the blood streams of depressed teenagers, some of whom had already become discouraged because standard antidepressant medications were either ineffective or made them worse. “Oxies,” many of them said, were the only drug that ever made them feel good. But because Oxycontin on the street was so expensive, many turned to cheap, readily available heroin. Lives descended into chaos; grades plummeted; trust was shattered as youngsters stole from their parents; capable students dropped out of college too ashamed to ask for tuition refunds; young parents neglected their children. Meanwhile if, as there often was, there was an underlying psychiatric disorder, it went undiagnosed and untreated.
When dual diagnosed youngsters are evaluated psychiatrically, a frequent pattern emerges: well before the first opiate is ingested many report early onset of suicidal depression or unrelenting anxiety. “How sick was it,” many a flailing student or college dropout said, “for the nine year me to be thinking about hanging myself or jumping in front of a bus?”
Decades ago we didn’t appreciate that standard antidepressants often make Bipolar Disorder worse. Now, once these patients are stabilized on Buprenorphine, they are free to participate in therapy that addresses their psychiatric issues, often time with amazing results.
So: does the doctor prescribe a medication that may be necessary for the indefinite future? Or does he taper and have his patient commit to intensive drug rehabilitation therapy and hope that he can treat comorbid bipolar disorder at the same time?
I would gladly recommend the latter if it was safe, but many calls over the years about bipolar buprenorphine-treated young adults who relapsed and overdosed after they tapered or discontinued buprenorphine, have made a deep impression. One father of a young child relapsed on injectable heroin laced with fentanyl and surely would have died had not his parents found him unresponsive on the bedroom floor. While taking buprenorphine, the young man, who had many symptoms of bipolar disorder, readily dismissed offers to use heroin when he passed old drug buddies on his way to community college. Without buprenorphine on board to attenuate urges to use, he impulsively gave in to an urge to use when approached by someone in his old crowd. Fortunately he survived and is about to graduate college. He decided to resume buprenorphine maintenance. This is the dilemma doctors, patients and families face.
Stay tuned for advances in pharmacologic management of opiate use disorders. Many dedicated scientists are working on the problem. For doctors working with opiate disordered patients, progress can’t come soon enough; until then emergency room physicians or EMTs will remain charged with the heartrending task of telling a parent or friend that their loved one has died from a drug overdose.