duration of treatment with buprenorphine

Buprenorphine Post
crmark
Posts: 38

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

I understand and appreciate your sentiments. Bupe certainly seems to save some lives...for the short term. What's happening in the long run? Are we postponing their demise? This is what I see from where I stand as med. dir. of a residential treatment center: young adult after young adult, coming in for 3rd, 4th, 5th...10th, 11th, 12th treatment. ALL have tried Suboxone, most via one or more "legitimate" clinics and for durations of months to years. Vast majority have diverted, sold and/or abused their Suboxone IV. Obviously none in our "n" have maintained sobriety. Even after they leave our center many still go right back out and die. We've had the most success when we can get 1-2 Vivitrol injections in before they discharge and they continue the injections for many months to a year. Here and elsewhere I hear of the anecdotal reports of successful maintenance patients who have been on bupe for years-may be true. Where are the long term studies? There should be some 5, 10 and even 15 year success rate data somewhere in the 15+ years since DATA 2000? I feel the tragedy to kcairns. I'm just wanting to avoid "kicking the can on down the road"...

kcairns
Posts: 571

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

families of those who died waiting to heal might wish them back

crmark
Posts: 38

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

Thank you and much applause entjwb! Addiction is a disorder of the mesolimbic dopamine reward system, not an opioid deficiency. 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
Posts: 38

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

Thank you and much applause entjwb! Addiction is a disorder of the mesolimbic dopamine reward system, not an opioid deficiency. 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.

entjwb
Posts: 180

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

I discuss the goal of weaning off the Bup on the first visit. I don't believe a trade one drug for another drug, even if a lot safe, should be the goal of a treatment program like this. I just talked with a patient yesterday who has been weaned off for Three months and still doing fine no cravings or problems. I also saw a former patient, weaned off three years ago who has totally gain his life back. I believe most everyone in this treatment program becomes mentally addicted to the Bup. They are so much better than they used to be and don't want to go back to that previous life. That is the most difficult part of the program. I stress and motivate the patient to get their self worth and value back. I have found that once that occurs the weaning process becomes easier. During the weaning, I give the patient control of the weaning process and I orchestrate how they can do it. They know they can control their life again because they are controlling it. My goal is not 100% abstinence but 100% control. They may be given opiates post op or in serious accident. So self control must be used o prevent relapse. Just my way of thinking regarding addiction therapy.

Dave
Posts: 187

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

A heavy handed taper won't work. Some patients may have to remain on bup all their life. At least that is better than a taper that leads only to relapse and possible overdose when the patient takes his "usual" dose of heroin or whatever and has no more tolerance to the high dose.

gordon2441
Posts: 12

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

Brand new at this (just over 1 year). I have been suggesting to my highly motivated patients to decrease the dose by 1/4-1/2 film on their own (only on relatively stress-free days), and tell me how they are doing on the next visit. I always prescribe the dose that makes them symptom-free, and let them taper themselves. I do understand that this strategy is susceptible to abuse, but I think it makes more sense than for me to impose a heavy handed taper that might very well be inappropriate for their needs.
Comments ??

Clark

drpasser
Posts: 1404

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

I don't think those agents are a bad idea. Seligeline is an MAOI, at low doses, one does not have to avoid eating foods containing the amino acid Tyramine. But at higher doses, Seligeline can cause a Hypertensive Crisis, so a Tyramine free diet is indicated. That means, pts cannot have foods like Cheese and aged foods and meats like Salami. In the old days, we used a lot of MAOIs, before any of the SSRIs were available. Seligeline comes in a skin patch. A low dose isn't a bad idea, but I've never used it for this purpose here, i.e. To help get pts off of bupe. It is an interesting idea. Typically, Seligeline is felt to have its main action in the Basal Ganglia and is used for Parkinson d.

L-methyl Folate, is a Folate precursor which more readily is centrally acting, compared to Folic Acid. It's what is known as Precursor Therapy. I have never used it for this purpose either.

Interesting ideas though.

Best
Kevin

kcairns
Posts: 571

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

i have read from Dr Howard Wetsman CMO of Townsend Addiction Treatment Ctrs in LA about (following genetic testing) the use of, for increasing dopamine tone, l-methylfolate and selegiline....? anyone w knowledge/feeling re this?

Dave
Posts: 187

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

Kevin, Thanks for the additional info on the max dose of bupropion. I hope to be able to help some people with that. It would be nice to have something to prevent relapse that so often occurs weeks or months after rehab or cold turkey.


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