For most of the last century, the ability of doctors and treatment centers to help opioid addicts has been limited by the federal government. The Harrison Narcotic Act of 1914, originally designed as a tax act, was interpreted by the Supreme Court to prohibit the prescription of opioids to opioid addicts, even in the course of their treatment. From then on, an entire line of practice – the tapering of opioid dosage to ease the pain of withdrawal – was against the law.
One exception was methadone. When used properly, methadone maintenance is an effective treatment for opioid addiction: it blocks the effects of other opioids like heroin and greatly improves the patient’s psychosocial stability. Unfortunately, hostility to the idea of maintaining addicts on a substitute drug has led to federal restriction of methadone that is so tight that the drug can only be prescribed by specific clinics. These clinics vary widely in the quality of care they provide. Additionally, methadone can cause euphoria, which can increase the probability of relapse. The combination of these factors has limited methadone’s effectiveness as a medication not only for maintenance, but for detoxification as well.
In the latter part of the twentieth century, the medical management of opioid withdrawal was largely left to treatment centers, where physicians could prescribe only a handful of symptomatic medications. Opioid addicts who could not afford medical treatment are left to detoxify themselves “cold turkey,” which usually results in a return to opioid drug use.
Now there is hope on the horizon. The Drug Abuse Treatment Act of 2000 allows the prescription of buprenorphine to opioid addicts to ease the symptoms of withdrawal. Whereas drugs like morphine, heroin and methadone are opioid receptor agonists – meaning they fully bind opioid receptors – buprenorphine is a partial opioid receptor agonist. This gives buprenorphine the ability to relieve the symptoms of opioid withdrawal without producing the euphoria of the full agonist drugs like methadone. For the first time, physicians can use buprenorphine to provide a comfortable detox for opioid addicted patients, thereby setting the stage for more effective inpatient or outpatient treatment.
Buprenorphine is available in two forms: a sublingually (under the tongue) administered tablet containing only buprenorphine (Subutex), and a sublingually administered tablet containing buprenorphine and the opioid antagonist (blocker) naloxone (Suboxone). Suboxone eliminates the danger of abuse of the opioid component of the medication: administered sublingually, only the buprenorphine is absorbed, but if the patient attempts to inject Suboxone, the opioid antagonist blocks the effect of the buprenorphine. Subutex and Suboxone are manufactured by Reckitt-Benkiser.
Perhaps the most important feature of the Drug Abuse Treatment Act and the availability of Subutex and Suboxone, is that it gives the ability of physicians to treat addicts in the privacy of their office. Patients no longer need to travel to substandard clinics to receive help for their addiction. As mandated by the DATA, physicians wishing to prescribe buprenorphine must complete the instructional course on the protocol for Office-based Opioid Treatment given by the Center for Substance Abuse Treatment. A listing of certified physicians can be found at www.buprenorphine.samhsa.gov.
Suboxone has been available for about one year. The results have been staggeringly positive. In the past, many opioid addicts attempting to achieve sobriety by the old methods (medical detox or “cold turkey”) failed to complete their detoxification. Now those patients are completing detox and entering treatment. Patients prescribed Suboxone are reporting that for the first time they feel some hope.