duration of treatment with buprenorphine

Buprenorphine Post
gordon2441
Posts: 12

Postby gordon2441 » Mon Mar 17, 2014 11:24 am

Rick,

It is fascinating that you haven't a single patient who has been completely weaned off Bup. I haven't been in this business long enough to confirm your finding, but if those on this forum agree with you, it is possible that "getting off" bup may be an unrealistic goal. (The majority of my patients expect it, though)

I'm curious to know what is the lowest dosage for maintenance, in your experience. Thanks

Gordon

Dave
Posts: 187

Postby Dave » Mon Mar 17, 2014 11:24 am

rickbennettmd, I agree completely with this point of view. It is what I do too.

rickbennettmd
Posts: 90

Postby rickbennettmd » Mon Mar 17, 2014 11:24 am

regarding our thread's title subject, "duration of treatment":

I often explain to my patients who inquire about this as follows:

"Taking Suboxone chronically in a responsible way will not hurt you. However, studies have reliably shown that relapse occurs more often than not on those who discontinue their Suboxone (or methadone) therapy. As you know, relapse can destroy your life, and it can even kill you."

This personal realization has led me to conclude that I will never take a patient off of buprenorphine therapy unless they expressly desire this.

I have had no patients follow through with this total wean from medication yet, though it is not unusual for a patient to state this goal in the course of treatment. Typically at some point in their taper patients realize that they benefit from or require some minimum daily dosage.

However, if I ever do have a patient wean completely off of their medication I will certainly counsel them carefully. Lifelong continued meeting attendance, and also to some extent follow up should be strongly advised.

Finally, I will add that my observation at our recent ASAM meetings is that chronic therapy is becoming accepted as standard therapeutic philosophy by both active practitioners and by the leaders in our field. Speakers relate this chronic therapy as equivalent to our practice of prescribing medication indefinitely for other chronic diseases, such as diabetes, htpertension, and major psychiatric disorders.

Rick




rickbennettmd
Posts: 90

Postby rickbennettmd » Mon Mar 17, 2014 11:24 am

"The only way an already defective dopamine reward system, that has been further decimated by drug/alcohol use, can heal, is by abstaining from ALL substances that stimulate increased dopamine release in the VTA-NA, as illustrated quite elegantly by Nora Volkow's PET/SPECT scans and fMRI's of the brain." crmark

Mark

We must be REALISTIC. These are REAL people. As scientists we rely on data analyzed by the scientific method. As physicians we use this information to help our patients to the extent possible.

The harm reduction model points the way to the best care we can now provide our patients. Studies demonstrate unequivocally that patients' lives and health are improved far more utilizing our MMT therapy employing Suboxone than by any other therapeutic technique.

Our goal is not an abstract one. We are not trying to achieve an idealistic optimal goal of "curing" this notoriously chronic, refractory psychiatric disease.

Our goal is to improve our patients' lives here, now, in their real lives.

Suboxone is an absolutely amazing therapeutic drug used for this purpose by professionals. We who utilize this therapy witness almost miraculous therapeutic effects all day long every clinic day.

This uniquely effective drug is an absolute godsend for perhaps millions (?) now of patients with truly catastrophic illness.

It is our duty to use our medical data responsibly and support this care.

Rick

kcairns
Posts: 571

Postby kcairns » Mon Mar 17, 2014 11:24 am

Dr Mary Jane Creek who worked at the start of opioid substitution treatment with Drs Dole and Nyswander has published that nonmed rx alone adequately treats 20 % and with addition of medication 80 %, such can be found in pubmed w many references..."Health Affairs" about 2 yrs ago published work showing 75% mortality reduction when medication (mtd or bup) was added to non-med rx alone, etc etc..my own clinical experience preponderant of "you saved my life", of people loving life, of healthy babies and great maternal care...many many people really enjoy life..i know I do this unbelievable day as the mountains and lake begin to appear w the first lightening and day progresses to brisk air w sun glistening off the snowcapped range thru slight haze... I can almost see why people prefer life when well as opposed to those made suicidal d/t inability to access rx to bn. "if the doors of perception were cleansed everything would appear as it is --infinite --wm blake, proverbs from hell...fun talking to you, I love liveliness...also see above rickbennett post on thread of induction w neg uds

entjwb
Posts: 180

Postby entjwb » Mon Mar 17, 2014 11:24 am

Crack, I understand where you are coming from. But as others have said not every patient is going to be the same. I have found with working on each aspect that needs to be addressed with each individual patient it increases the chance of being able to wean off Bup and be fine. I have found, in my practice, and not all populations are the same either, that the addicted person has very low self esteem and self worth while using. That is the reason I work with them to bring the self worth and self esteem back into their lives. Many programs, in my estimation, are more punitive than encouraging. We are strict but encouraging with the patient. My population this approach works most of the time. But it doesn't in some patients. When I encounter a problem patient I suggest they do in patient rehab for at least thirty days. I will****ist them finding an appropriate place. Then they can return to continue therapy. I may be wrong in my approach but it seems to be working in the majority of my patients after they get their self worth and self esteem back. They then can control the addictive tendencies.

crmark
Posts: 38

Postby crmark » Mon Mar 17, 2014 11:24 am

"Bupe is well known by most of us to stabilize most patients for years." Great! So you could possibly point me to the data that supports that contention?

Dave
Posts: 187

Postby Dave » Mon Mar 17, 2014 11:24 am

In the long run we are all dead. "Kicking the can down the road" is better than an early death. Even the proper treatment of moderately severe diabetes mellitus does not prevent death from complications eventually, hopefully far down the road. Bupe is well known by most of us to stabilize most patients for years. Some are not ready for that and still want to escape reality by getting high. Just as we cannot cure all mental disorders, we cannot cure every person with drug dependency. Actually that word "cure" is used very optimistically. It's rather like the AA and alcoholics, once an addict, always an addict. But you can learn to say NO.

kcairns
Posts: 571

Postby kcairns » Mon Mar 17, 2014 11:24 am

respect you both, cordiality always w every one in this work, ken, I am not snappy just enjoy talking snappy sometimes...just as w you two, my experience is what it is and to me it is very believable

sslonim
Posts: 118

Postby sslonim » Mon Mar 17, 2014 11:24 am

Before I got in to medicine I remember a doctor (family friend) telling me I would never have 2 patients exactly the same. Every case is different/individualize. I think the same applies here - both for our patients and for each of us as providers (we may be seeing different patient populations). I have had a few patients be able to go off Suboxone. I have many patients who I've followed for years who have done well - many on low doses but not able to go off. I have some patients that struggle/relapse at times but resume Suboxone. Many patients who do well with Suboxone but have many other medical (anxiety, ADD, depression, diabetes, pains, etc.) and social (criminal history, lack of job, transportation, etc.) problems. I certainly have had patients that have not come back - they may be the ones crmark refers to. (I had one that another patient later told me committed suicide - when I last saw him he said he was going to go off both Suboxone and his psychiatric/MDI meds.
So, I'd like to think that both sides may be correct. It would be great to get patients off all meds but some/many do well with continuing Suboxone. Sam


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