Respect, not coddling, for buprenorphine patients | Addiction Professional Magazine Skip to content Skip to navigation

Respect, not coddling, for buprenorphine patients

April 11, 2018
by Sylvester Sviokla, MD
| Reprints

The opioid scourge continues unabated. People continue to die at a record rate in spite of ever-increasing news coverage of illicit drug use. How can this be?

While friends, family members and others not dependent upon drugs view the flood of information with appropriate alarm, active opioid users do not. They wonder about the newer, stronger street drugs, especially fentanyl, and what it must feel like to find some. Most are sure they will use it wisely. Most do not think they will die. Some do think they might, but are willing to risk it.

How do I know they think this way? I am recovering from opioid addiction (17-plus years), and the thought does not shock me. More importantly, there is a recurrent behavior that provides empirical evidence that impaired thinking pervades the drug-using community.

The promulgation and use of the first aid medication naloxone (Narcan) by healthcare providers, law enforcement and education institutions has offered a window into opioid use and attempts to treat it. Naloxone also is being given to many individuals with opioid addiction who leave various treatment settings for use should they relapse. Consequently, large numbers of patients who relapse are being given the drug, and most are arriving at emergency rooms alive rather than dead. Though this represents progress in initial survival, there is much more to the story.

One would think that these patients would be relieved to have cheated death and would be ready to start a serious attempt at beginning treatment. But this rarely describes the actual scenario. Although naloxone has allowed the patient's breathing to begin again and can help restore a viable blood pressure, the patient quickly awakens in full-blown opioid withdrawal. Under these circumstances, the patient will agree to most any follow-up plan, as long as it starts tomorrow. The immediate need to relieve the worst withdrawal the patient has yet endured becomes paramount in the patient's mind. The addict must use again, as soon as possible. He will leave, against advice if necessary, leaving loved ones and friends bewildered. Chances are, if he doesn't die, he will be back again.

In my capacity as medical director of Phoenix House in Rhode Island, I have seen scores of patients admitted for detoxification and treatment as they continue in their addiction. Many readily admit to having suffered multiple overdoses requiring naloxone reversal within a one-year period. They are aware they are lucky to be alive, and often offer no promises that it will not happen again.

Although the public is baffled by such behavior, we providers cannot be. Respecting the power of a disease that so often brings the patient to the edge of death mandates our attention and resolve to avoid being deceived by our patients.

A boost from medication

It is in the milieu of an opioid treatment center that the patient has the best chance for success. The patient should be offered medication-assisted treatment options. They include: methadone maintenance clinics; naltrexone, orally or in the form of monthly Vivitrol injections; and buprenorphine-assisted recovery. Here I will discuss the latter, as I believe it has been proven to work best for the majority of opioid-dependent patients. This medication has several qualities that make it ideal for those patients who wish to stop using now.

Buprenorphine is a partial agonist (activator) of the mu (opioid) receptors in the brain. It is at these receptor sites where nearly all the damage caused by opioid addiction starts and develops. Here is where tolerance for the opioid occurs. Tolerance is a need to take more of the drug, in use over a shorter period, in order to achieve the same result as when it was first taken. It is also at these receptors where healing can begin quickly by employing the appropriate introduction of buprenorphine into a formally scheduled treatment program.

The patient must be induced (started on the drug) when he/she is in sufficient opioid withdrawal. The state is best determined by a trained provider who uses history, physical examination and urine drug screen results. Although the medication enters the peripheral blood system as soon as it dissolves in the mouth, it will take another 45 minutes for it to cross the blood/brain barrier. The buprenorphine then will quickly attach itself to every mu receptor it can find. Those empty receptors are demanding activation by more opioid in order to stop the tremendous life-controlling dysphoria that has brought the patient near death and now to treatment.

The affinity (adhesiveness or stickiness) of buprenorphine for these mu sites is stronger than that of the common drugs of abuse and will immediately bond with the receptor and not allow other opioids to occupy that space. But instead of fully activating these sites, it will only partially turn them on. This amount of site activation will immediately begin the reversal of the patient's discomfort, but will not activate the receptors enough to reinstate the “high” initially felt by the patient. This limited amount of activation will, however, eliminate the desire to take more of the opioid of choice.

In addition, this small amount of mu activation will provide a slight energetic boost, but is not so energy-producing that the drug develops the tolerance that occurs with all other abusable opioids (including methadone). Practically speaking, this means that the newly induced buprenorphine patient will not feel better by taking more than his particular prescription dosage, but will instead begin to feel dysphoric and nauseated. This absolutely discourages and most often prevents overuse.


The Summits for Clinical Excellence bring together thought leaders on cutting-edge topics in multi-day national and regional conferences. Summits on mindfulness, trauma, process addiction, and shame appeal particularly to private practice behavioral healthcare professionals. Other Summits address the national opioid crisis from a regional perspective and engage a diverse group of stakeholders.

June 25-26, 2018 Pittsburgh — The Opioid Crisis: The Clinician's Role and Treatment Practices