28 May Buprenorphine Tapering Less Effective for Prescription Opioid Addiction
Prescription drug abuse is a huge problem in the U.S., and determining the most effective ways to help people struggling with it is an understandable priority for public health. Many physicians opt for a “tapering” approach to detoxification, where an alternative opioid like buprenorphine or methadone is prescribed in a gradually-decreasing dosage. The theory is that this will enable those addicted to drugs like OxyContin to reduce their dependence while also minimizing withdrawal symptoms, but a new study has indicted that tapering using buprenorphine doesn’t work as effectively as simple maintenance using the same drug.
Prescription Drug Epidemic and Buprenorphine
Every day in the U.S., 114 people die from drug overdose, and in 2012 just over half of these deaths were related to prescription drugs. Opioid painkillers were involved in 72 percent of the prescription drug-related deaths, making them the single biggest contributor to the growing problem. These painkillers are so addictive (and dangerous) because they’re chemically related to heroin and they interact with the brain in a virtually identical fashion. Although some fall into addiction after being prescribed the drugs for a legitimate medical purpose, most people who end up addicted seek them out as a recreational drug.
Buprenorphine is a popular choice for the treatment of opioid addiction because it’s a “partial agonist,” meaning that it binds to opioid receptors, but not as strongly as heroin or methadone. Since it doesn’t bind as strongly in the brain, the euphoric effects and its addictiveness are reduced. The drug is often combined with naloxone (which blocks the effects of opioids in the brain) so that if somebody attempts to take large doses of the combination medicine, it won’t produce the desired effect.
Ongoing Maintenance or Tapering?
The researchers aimed to investigate the effectiveness of tapering the dose in comparison with buprenorphine maintenance (using a consistent dosage). They recruited 113 patients who were addicted to prescription opioids, who were then randomized to receive either the tapered dose or the maintenance dose. The tapered dose involved six weeks of stabilization followed by three weeks of tapering (reducing by 2 mg every three days from a starting point of 15 mg per day). If participants were abstinent from opioids for one week after their last dose, they were offered naltrexone (similar to naloxone), and all patients received ongoing clinical support and counseling.
Tapering Reduces Odds of Abstinenc
The main finding of the study can be summarized simply: tapering is not as effective as using a maintenance dose. Those in the taper group had fewer urine samples testing negative for opioids (35 percent in comparison to 53.2 percent), used illicit opioids more often per week (an average of 1.27 times compared to 0.47), were abstinent for fewer consecutive weeks (2.7 compared to 5.2) and were much less likely to complete the trial (just 11 percent completing in comparison to 66 percent of the maintenance group). No matter how you look at the findings, maintenance appears superior to tapering.
This finding fits with existing evidence on the most effective way to use methadone, where studies show that heroin users are more likely to remain abstinent when on a maintenance dose rather than a tapered one. Lead author Dr. David Fiellin points out that because of the less severe withdrawal associated with buprenorphine, many physicians thought that the evidence base for methadone wasn’t directly relevant. However, the new finding shows that for those dependent on prescription painkillers, receiving buprenorphine is much the same as for heroin abusers receiving methadone.
Buprenorphine: Poor Implementation or Poor Treatment?
The big question raised by the study is whether we need an alternative approach for treating those struggling with prescription opioid abuse or whether it’s simply the implementation of the existing methods that is the problem. Some have argued that six weeks of stabilization prior to tapering isn’t sufficient, so this may be responsible for the issues identified by the study. Given that addiction is a chronic and relapsing condition, no matter how appealing an “almost surgical cure for addiction” (in Dr. Fiellin’s words) is, it isn’t realistic to “cure” the issue over a short period of time.
The problem with this approach is that by taking an alternative opioid for a long period of time, addiction simply continues. There may be reduced harm, but ultimately the issue has been shifted onto another substance rather than rectified. This is why some argue that studies like this show why novel treatment options are needed for opioid-dependent individuals.
Avoid Tapering Until There’s a Better Option
Although there is some disagreement about what should be done to improve opioid treatment, this study makes one thing clear: tapering doesn’t seem to work. The real mainstay of treatment is the psychological side — addressing the underlying reasons for why you’ve become dependent on opioids and learning healthier coping mechanisms. Once this is accomplished, tapering may be able to assume a limited role as a withdrawal-minimizing addition to the core elements of treatment, but it is highly unlikely to be an effective approach in its own right.
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