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Buprenorphine Naloxone and The Opioid Crisis

Beyond Addiction

Buprenorphine Naloxone Combination For Opioid Addiction Treatment

Buprenorphine naloxone combination is a medicine used for opioid addiction treatment. In addition—the buprenorphine naloxone combination can also be used as pain relief or pain management. This opioid addiction treatment is only for opioid-dependent patients. It should never be shared with another person—especially with someone who has a history of opioid addiction or drug abuse.

A combination of the opioid drug with an opioid antagonist—such as Suboxone (buprenorphine naloxone combination), was approved by the FDA back in 2003. It is meant to be used as a treatment for drug abuse and substance abuse treatment—especially for opioid addiction—by opioid-dependent patients where buprenorphine is mixed with naloxone (an opioid antagonist).

Buprenorphine treatment is available as a sublingual buprenorphine tablet and film. This formulation can reduce opiate addiction compared to the standard buprenorphine dose of tablets.

Buprenorphine Naloxone and other Frequently Asked Questions

In the late 1990s, pharmaceutical companies reassured physicians and other providers that patients wouldn’t become addicted to opioid pain relievers.

As a result, healthcare providers began to prescribe them at increased rates to comply with addressing the “5th vital sign” and improve patient satisfaction.

This led to more patients becoming dependent on opioids as well as more opioids available for diversion. In 2017, an estimated 2 million people suffered from opioid use disorder–both prescription opioid and heroin use disorder.

Let’s use nicotine as an example. A person may use nicotine and find themselves needing more than the original amount to have the same positive effects. This is defined as tolerance.

When the person doesn’t use nicotine they may have negative side effects, this is defined as withdrawal.  Wanting to have nicotine and it being on your mind is defined as craving.  Using the money you may have saved for something else relates to the compulsion associated with addiction.  

So when an individual uses a substance and then misuses or abuses it, that leads to dependence or addiction

Once the neurobiology of the brain has been altered secondary to misuse or abuse a person may have a chronic lifelong addiction or use disorder.

I am waivered to prescribe buprenorphine, both Suboxone and Subutex. If the patient prefers to take either of these medications, I am able to prescribe these medications and work with them to manage their continuous care both during and after pregnancy.

If they have been on methadone and are stable, then it is recommended that they continue to use methadone. Patients on methadone would see me for their obstetric care and obtain their prescription of methadone from a methadone clinic.

Regular use of opioids increases the chances of being dependent or addicted. This is why doctors are discouraged from prescribing patients opioid pain relievers for chronic pain like headaches, back pain, or pelvic pain that hasn’t been evaluated by imaging or other diagnostics

Opioid pain medication is best for acute pain like a broken bone, just after surgery, or in terminal (end of life) circumstances. 

Oxycodone is made by modifying Thebaine, an organic chemical found in opium. Hydrocodone is semisynthetic, made from codeine.

Hydrocodone has a longer half-life than oxycodone, so it stays in your system longer. For instance, hydrocodone can be detected in your system for 2-3 days after ingesting. Of course, taking either for a long period of time may result in developing a “physical dependence” on them.

Norco is the brand name of the combination drug that has hydrocodone and acetaminophen (Tylenol).

Pentazocine is an opioid agonist and when combined with naloxone, an antagonist, you have the brand name medication Talwin NX.  Talwin NX is used to treat pain–not for opioid dependence.  

Pentazocine is an agonist at the K-opioid receptor, unlike most other opioids, which primarily act at the mu receptor. 

Opioid use disorder is classified as mildmoderate, or severe depending on the number of criteria met. There are 11 criteria that are evaluated if 2-3 are present that would be considered mild, 4-5 moderate, and 6 or more severe. 

The current MAT is Methadone, Suboxone (buprenorphine/naloxone), and/or Subutex (buprenorphine alone) which is really only used during pregnancy
Suboxone has naloxone added to prevent the medication from being tampered with and used intravenously.  We use Subutex in pregnancy because of the concern that the naloxone could stimulate withdrawal in the pregnant patient and cause untoward effects in the fetus.

All three of the MAT medication work well. Methadone is a full agonist and as a side effect has the same ability to decrease respiratory effort as any other opioid. It can only be obtained from a methadone clinic. 

Suboxone is a combination drug, including the partial agonist (buprenorphine) and antagonist (naloxone).  The buprenorphine has a greater affinity for the mu receptor but does not have the same ability to decrease respiratory effort or symptom relief. This is called a ceiling effect. As a result, this has rendered the drug safer than methadone

A lot of research is being done in the space of pregnancy, opioid use disorder, and the effects on newborn babies.  Current literature suggests buprenorphine has earlier and shorter neonatal abstinent syndrome (NAS) than methadone.

Buprenorphine can be prescribed by doctors with an X waiver on their DEA registration. This is often more convenient for patients especially when they are far away from a methadone clinic.

The Opioid Crisis (Epidemic)

In the late 1990s—pharmaceutical companies reassured physicians and other providers that patients wouldn’t become addicted to opioid pain relievers. As a result—healthcare providers began to prescribe them at increased rates to comply with addressing the “5th vital sign” and improve patient satisfaction.

Beyond Addiction

This led to more patients becoming dependent on opioids, as well as more opioids available for diversion. In 2017, an estimated 2 million people suffered from opioid use disorder–both prescription opioid and heroin use disorder.

What is Opioid Addiction

Opioid addiction is a long-lasting (chronic) disease that is being catered by human services because it can cause major physical and mental health, social, and economic problems. Opioids are a type of drug—which act in the nervous system—producing feelings of pleasure and pain relief. However—Addiction treatment may be necessary for people who misuse such drugs.

However—some opioids are legally prescribed by healthcare providers to manipulate severe and chronic pain. Commonly prescribed opioids by human services include—oxycodone, oxymorphone, hydrocodone, fentanyl, buprenorphine, morphine, methadone, and codeine.

Other opioids are being abused—such as the illegal drug—heroin. The drug addiction treatment act helps lessen opioid addiction to heroin—which is characterized by a strong and obsessive desire to use opioid drugs without being medically required.

Drug addiction treatment act—as well as—a maintenance therapy, helps people stop addiction to opioids because such drugs also have a very high potential to cause addiction to some people and yes—even when taken as prescribed. 

According to J addict or Journal of Addictive Diseases—people who become addicted to opioids may prioritize using such drugs over other daily activities and often impact their personal and professional lives negatively because of the opioid withdrawal symptoms—such as respiratory depression. Though the reason is still unknown why there are some people who are more likely to become addicted compared to others.

Opioids change a person’s brain chemistry—leading to drug tolerance. This means—over time, either the full or partial opioid agonist dose needs to be increased in order to achieve the same effect. When you are taking opioids for over a long period of time—it produces dependence—such that when you stop taking the drug—it causes physical and psychological opioid withdrawal symptoms.

The Difference Between Opioid-Dependent Versus Being an Opioid Addict

Opioid dependence and opioid addiction are different. Although most people confuse both dependences on opioids and opioid addiction—there are several distinctions between the two conditions. For example—people who are dependent on Cns depressants are referred to as being physically dependent on the substance (Cns depressants). Dependence is distinguished by the manifestation of withdrawal and tolerance. Although it is possible to keep a physical dependency without becoming addicted to it—but addiction is just right around the corner.

On the other hand—addiction is characterized by a behavioral change generated by the biochemical adaptations in the brain after continued substance abuse. The use of substances becomes the main focus of an addict—regardless of the damage they may cause to others or themselves.  Addiction causes a person to act irrationally whenever they don’t take the substance they are addicted to into their system.

How to use Sublingual Buprenorphine as Substance Abuse Treatment

A healthcare provider will give you a medication guide along with your Sublingual Buprenorphine. For a more effective treatment—patients undergoing this addiction treatment should only use this prescription drug as directed by the healthcare provider. This prescription drug is placed under the tongue for 5 to 10 minutes until it dissolves completely. 

If the patient is prescribed more than one buprenorphine dose every day—all tablets can be placed under the tongue at once. Just remember that sublingual buprenorphine addiction treatment should not be swallowed nor chewed—as it will become ineffective. After the sublingual buprenorphine totally dissolves under the tongue—take a large gulp of water and gently swish it around your gums and teeth—then lastly—swallow the water. Doing so helps in preventing problems with your teeth. 

Sublingual buprenorphine is commonly used for the first two days after the opioid withdrawal. Buprenorphine treatment also prevents Opioid withdrawal symptoms—especially severe withdrawal symptoms. Taking sublingual buprenorphine right after opioid withdrawal symptoms begin makes it more effective.

However—if sublingual buprenorphine is taken too soon or just right after using an opioid—then it will cause severe withdrawal symptoms. A patient’s sublingual buprenorphine dosage depends on the patient’s medical condition—as well as their response to the treatment. This is why healthcare providers strongly discourage increasing sublingual buprenorphine dosage without the doctor’s advice.

Also—if the patient suddenly stops taking sublingual buprenorphine—it can cause withdrawal symptoms—especially if the patient has been taking it for a long time. To prevent withdrawal symptoms—you may ask your doctor to lower your dosage gradually. Patients should consult the doctors right away if they are experiencing any withdrawal symptoms—such as breathing problems or respiratory depression, restlessness, mental health problem—especially anxiety (the feeling is similar to respiratory depression), and sudden mental and behavioral changes.
Patients should never inject buprenorphine hydrochloride without consulting a healthcare provider first. Injecting buprenorphine hydrochloride could cause withdrawal symptoms that could ruin the patient’s physical and mental health.

Methadone For Opioid Dependency in Pregnancy

I am waivered to prescribe buprenorphine—both Suboxone and Subutex. If the patient prefers to take either of these medications—I will prescribe these medications and work with them to manage their continuous care both during and after pregnancy.

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