We’ll start this article with some Dr. F self-disclosure. As you are looking at the X-ray of the handiwork of my orthopedic surgeon, try and realize the discussion I had regarding my fractured elbow:
One year later, I indeed had my elbow hardware removed and have an overall wonderful outcome to my elbow fracture (it was a bicycle accident, btw).
When you are struggling with opioid addiction, it really is a full lifestyle. It overtakes your friendships, finances, career, loved ones, and general ‘brain real-estate.’ Addiction takes everything. The pull of these forces is very analogous to the tendon pull on my elbow. By stabilizing things with a medication such as Buprenorphine, you are able to address some of these healing points one by one. Most people ask about a buprenorphine or Suboxone taper. Ultimately, I tell them my opinion about how to succeed. If you make numerous changes in your life, you can essentially ‘earn’ your way off Buprenorphine. People who resist change tend to be kept on the med. Had my elbow shown poor overall healing, I’m sure the hardware would have stayed put. Buprenorphine is surgical hardware.
Buprenorphine treatment works. The medication has an overall strong effect size. Article analysis reviewing the efficacy of this medication includes some of the following clinical literature:
In reviewing multiple journal articles, there are common themes of Buprenorphine being very helpful for treatment retention, preventing opioid use at moderate or higher dose ranges, and preventing death. Buprenorphine is the standard of care for opioid addiction treatment today.
After reviewing the above information and clinical content, we are left with the dilemma of determining how long a patient should be maintained on Buprenorphine and whether or not they should be tapered off the medication. Some of the clinical studies reviewing this are as follows:
In terms of strategy involving Buprenorphine taper and then a bridge onto Naltrexone medication, the following study showed the most promising results:
This lets us believe that tapering off Buprenorphine is possible and can be done through different strategies. One study supported more of a 4-week rather than 1 or 2 week taper. The other study supported a 1-week taper combining with Naltrexone to speed up the transition.
It is important to note that the Naltrexone-aided taper would be best suited for a patient looking to bridge onto Naltrexone, an opioid blockade medication, for the first few months of being off Buprenorphine. This can ideally be done with the use of injectable Naltrexone (Vivitrol) to ensure compliance.
The most common additional medications prescribed to people progressing through a Buprenorphine taper include:
These medications tend to be safe for symptoms including sweating, agitation, insomnia, and anxiety. Of note, the only particularly dangerous med of these 3 is the clonidine, as it can cause severe hypotension and death when taken in excess. We counsel people to stay accurate with the prescription and not to expect a complete resolution of symptoms from something like clonidine. These medications will soften some of the withdrawal but are not powerful enough to completely take withdrawal away.
The only thing really powerful enough to take away Buprenorphine withdrawal is… Buprenorphine
Which leads us to a primary dilemma with this process. Buprenorphine tapers seem to only work when the medication is completely cut off from the patient, such as in residential treatment settings or with firm boundaries from a prescriber. Many people will work to taper down the medication and fail in their attempt. Most of the above-listed studies involved close monitoring of the medication and dispensing of doses through a center. This is different than with self-administered treatment approaches.
In connecting this to my fractured elbow example, an ideal patient to taper Buprenorphine would have the following traits:
Only if you meet the above-listed criteria, and that includes every single one of the above, you may be a good candidate to taper down your dosage. Talk to your provider about some of these issues so that you can build a collaborative plan moving forward. If any of the above are not applicable to you or are too difficult, the hardware needs to stay in.