How buprenorphine, or ‘bupe,’ changed opioid addiction treatment
Confronting America's opioid epidemic
Now that we’ve established the effects of opioid abuse on the brain, we can better understand how medications like buprenorphine work to treat opioid addiction.
Buprenorphine is what’s known as a partial agonist opioid, meaning it activates people's opioid receptors enough to prevent them from feeling withdrawal but not enough to get them high. It’s also characterized as “sticky” because of its ability to latch onto the opioid receptors and block other substances from taking effect. So if you were taking buprenorphine and decided to use heroin, for example, the buprenorphine would prevent the heroin from getting you high.
Unlike methadone, which has more side effects and can cause overdoses if abused, buprenorphine also has what’s known as a ceiling effect.
“If a patient decides they want to get a high from it by doubling their dose or tripling their dose, they won’t,” explained Dr. Andrew Kolodny, chief medical officer at Phoenix House, a national nonprofit drug and alcohol treatment organization based in New York. “The maximum dose would be four strips. If you take 10 strips, you won’t feel any different than if you took four strips, whereas with any opioid, methadone or any other opioid, the more you take the more of the effect, to the point where you stop breathing.”
The passage of the federal Drug Addiction Treatment Act in 2000 allowed doctors with certain qualifications to prescribe medications such as buprenorphine to treat opioid addiction.
The act, known as Data 2000, made it possible for people with opioid addictions to seek treatment from doctors in a private, clinical setting. But access to this kind of treatment was heavily restricted from the start.
In 2002 the Food and Drug Administration approved two prescription drugs for the treatment of opioid dependence, Subutex and Suboxone. Both come in the form of dissolvable tablets, but while Subutex, containing only buprenorphine, is intended for detox, at the start of drug treatment, Suboxone combines buprenorphine with naloxone, a medication that reverses the effects of opioid drugs, and is intended for long-term, at-home use as a maintenance medication.
Buprenorphine has been credited with significantly reducing the rate of fatal overdoses since it was approved without restrictions for opioid addiction treatment in France nearly 20 years ago.
In 2011, the National Institute on Drug Abuse (NIDA) released the first large-scale study on the effectiveness of using Suboxone (buprenorphine plus naloxone) to treat opioid painkiller addiction in the U.S.
“The study suggests that patients addicted to prescription opioid painkillers can be effectively treated in primary care settings using Suboxone,” NIDA Director Nora D. Volkow said at the time. “However, once the medication was discontinued, patients had a high rate of relapse — so more research is needed to determine how to sustain recovery among patients addicted to opioid medications.”
Buprenorphine has also been recognized federally, by the Substance Abuse and Mental Health Services Administration, and internationally, by the U.N. Office on Drug Control Policy, as an effective tool for decreasing physical dependency on opioids and preventing fatal overdoses, especially following detox.
“I’ve seen a lot of people do very well [with buprenorphine]. I’ve watched my patients get married, have babies, graduate college, have very successful careers,” said Kolodny, who treated patients with the medication in his clinical practice for 10 years before going to Phoenix House.
“They would’ve liked to have come off of buprenorphine, I would have liked to get them off of it, because who wants to be stuck on a medicine?” he continued. “But it’s very hard. … Patients who did get off, it was not unusual for me to hear back from them maybe six months or a year later, often fully into a relapse with many of the same problems.”
In addition to his role at Phoenix House, Kolodny is the executive director of Physicians for Responsible Opioid Prescribing and advocates in favor of loosening the restrictions on doctors who prescribe buprenorphine. He compares the use of such maintenance medication for opioid addiction to treating diabetes with insulin.
“If somebody can address their diabetes through eating better and through exercise and through weight loss, that’s better than taking insulin,” he said. “You would never say to a person with diabetes, ‘I’m only giving you the insulin for a month; by then you’ve got to get your diet in check or too bad.’ Imagine how many people would go blind from their diabetes or lose a limb or have renal failure. It would be a public health catastrophe.”
“It’s better if you can treat medical conditions without pills,” he added. “But often it’s a lot harder.”
Read more from this series:
—This is your brain on opioids
—Abstinence vs. medication assisted treatment: Traditional 12-step programs embrace a new model
—The menace in the medicine cabinet: The opioid epidemic’s pharmaceutical roots
—The rise of Narcan, the life-saving opioid antidote that can stop an overdose in its tracks
—Why the new face of opioid addiction calls for a new approach to treatment
—Facing an epidemic of overdoses, Obama rejects governors' proposal to limit painkiller prescriptions
