The Drug Addiction Treatment Act of 2000
Signed by President Clinton on October 17, 2000, this law allows for a new office-based treatment of opioid withdrawal and addiction using buprenorphine.
The following restrictions apply:
1) The physician receives training in opioid addiction treatment.
2) The physician registers with Health and Human Services.
3) The physician receives a special number to add to his DEA license to prescribe scheduled drugs.
4) The drug prescribed is approved by the FDA as useful in the treatment of addiction. Buprenorphine meets those requirements. Subutex and Suboxone tablets were approved by the FDA on October 8, 2002. Suboxone film strips were approved on August 31, 2010.
5) The drug prescribed may not be a schedule II narcotic, but only III, IV or V. Buprenorphine is schedule III.
6) The physician may only prescribe medication to 30 patients at one time for the first year after certification. The physician can apply for approval to prescribe medication to 100 patients after that as needed. New regulations introduced in 2017 allow for select providers in qualified treatment settings to request to prescribe to 275 patients.
7) The physician must provide access to counseling services for the addicted patient either on-site or through referral to off-site providers.
The New Medication: Suboxone
Buprenorphine is a long acting opioid medication that only partially activates opioid receptors. Because of this, it has a ceiling of narcotic effects, which, along with its delivery mechanism, makes overdose much less likely, even in large dosages. The main form used is combined with a small amount of naloxone and marketed as Suboxone. The medicine is rapidly absorbed when dissolved underneath the tongue, and is not absorbed very well at all if swallowed. For these reasons, it is much less likely to be lethal in accidental ingestions by children. If Suboxone is injected, only the naloxone, an opioid antagonist, works and causes severe withdrawal for chronic opioid users.
Suboxone and Methadone
As buprenorphine is only a partial agonist, it is not equivalent in maintenance strength to higher dosages of the full agonists, methadone and LAAM. That is why a patient would have to be on a daily dose of methadone of 40mg or less to try Suboxone. There is a significant chance of relapse into opioid use for those on higher dosages of other treatments who try to wean down to use Suboxone.
What is an opioid?
Opioids are a class of drugs that frequently have a moderate or high level of addictive potential. Many are very effective for treating pain, and doctors frequently prescribe them for patients who have acute (like after an accident) or chronic (such as cancer) painful conditions. There are many opioid medications, such as Codeine, Vicodin, Percocet, Percodan, Demerol, Dilaudid, Morphine,, Roxicet, Roxicodone, Oxycodone, OxyContin and Opana. Methadone, LAAM (short for levo-alpha-acetyl methadol), and buprenorphine (i.e. the active ingredient in Subutex and Suboxone) are also opioids.
Why are opioids used to treat addiction?
Many family members wonder why doctors use Suboxone to treat opioid addiction, since it is in the same family as pain pills and heroin. Some of them ask, “Isn’t this substituting one addiction for another?” The three medications used to treat addiction to pain pills and heroin—methadone, LAAM and Suboxone—are not “just substitution.” The effects produced by these medications differ in important ways from the effects produced by, for example, the overuse of pain pills or an injection of heroin. These medications don’t produce the same kind of quick high that pain pills or a shot of heroin will produce, and they remain in the body a longer time—so the person doesn’t need to keep taking them several times a day (the way they take most illicit opioids). Since the medications are prescribed by a physician, the patient is on a stable and regular dose—unlike the often chaotic pattern of use with illicit opioids. Many medical studies since 1965 show that maintenance treatment helps to keep patients healthier, helps to keep them from getting into legal troubles, and helps to prevent them from getting transmissible diseases like hepatitis and AIDS. The same studies also show improvements in education and employment, as well as the preservation of family units.
What is the right dose of Suboxone?
Family members of persons who have been addicted to opioids have watched as their loved ones use a drug that makes them high, or loaded, or have watched the painful withdrawal which occurs when the drug is not available. Sometimes the family has not seen the “normal” person for years. They may have seen the person misuse doctors’ prescriptions for narcotics to get high. They are rightly concerned that the person might misuse or take too much of the Suboxone prescribed by the doctor. They may watch the patient and notice that the patient seems drowsy, or stimulated, or restless, and think that the Suboxone will be just as bad as the illicit opioids they were using.
Every opioid can have stimulating or sedating effects, especially in the first weeks of treatment. The “right” dose of Suboxone is the one that allows the patient to feel and act normally—the patient should not experience withdrawal (too little medication), and they should not be excessively drowsy during the day (too much medication). It can sometimes take a few weeks to find the right dose. During the first few weeks, the dose may be too high, or too low, which can lead to withdrawal, daytime sleepiness, or trouble sleeping at night. The patient may ask that family members help keep track of the timing of these symptoms, and write them down. Then the doctor can use this information to adjust the amount and time of day for Suboxone doses.
Once the right dose is found, it is important to take it on time in a regular way, so the patient’s body and brain can get back to a normal way of functioning.
How can the family support good treatment?
Even though maintenance medication treatment for opioid addiction works very well, it is not a cure. This means that the patient will continue to need the stable dose of Suboxone with regular monitoring by the doctor for some period of time—ideally at least a year. At that point, the goal would be to try and taper the patient off of the medication and maintain their recovery without the assistance of medication. This is similar to other chronic illnesses, such as diabetes, or asthma. These conditions can be treated, but there is no permanent cure, so patients often stay on the same medication for a long time. However, with appropriate behavioral modifications and life adjustments, many patients with chronic illnesses can get to a point where they can control their condition without the assistance of medication. While being assisted with Suboxone, though, the best way to help and support the patient is to encourage regular medical care, and not skipping or forgetting to take the medication.
Medication for opioid addiction is an important part of treatment, but addictions are complicated medical conditions, and often aspects of the illness outside the person (such as the availability of a drug, the people with whom the patient socializes, etc.) can play a powerful role in the disorder. Family members can support both the regular and appropriate use of Suboxone, and the other treatments (such as counseling) that are recommended by the doctor. It might be necessary or appropriate for spouses, significant others and/or other family members and friends to participate in counseling with the patient and/or independent of the patient for their own benefit.
Regular medical care
Patients will have ongoing visits for both counseling and doctor supervision. Most visits will be for counseling and the interval will be determined by the treatment team based on dynamic clinician assessment of the patient’s progress and need for support. For the first year of treatment, each patient will visit with the doctor on a monthly basis. After that, doctor visits will occur every three months unless otherwise indicated. If a patient misses an appointment, they may not be able to refill the medication on time, and may even go into withdrawal, which could be dangerous. The patient may be asked to bring the medication container to each visit, and may be asked to give urine samples at the time of the visit.
Special medical care
Some patients may also need care for other needle-related problems, such as hepatitis, or HIV disease. They may need to see their primary care doctor for blood work, or see several physicians for these illnesses.
All patients in our program will have individual counseling sessions with licensed or certified staff specializing in addictions care. Some patients may also require additional mental health therapy outside of our program or benefit from participation in group therapy. These appointments are key parts of treatment, and work together with the Suboxone treatment to improve success in recovery from opiate addiction. Sometimes family members may be asked to join in family therapy sessions, which also are geared to improve addiction care.
Many patients use some kind of recovery group to maintain their sobriety (such as Narcotics Anonymous, Rational Recovery, Smart Groups or 12-Step Programs). It sometimes takes several visits to groups to find the right “home” meeting. In the first year of recovery some patients go to meetings every day, or several times per week. These meetings work to improve success in treatment, in addition to taking Suboxone. Family members may have their own meetings, such as Al-Anon, to support them in adjusting to life with a patient who has addiction.
Taking the medication
Suboxone is unusual because is must be dissolved under the tongue, rather than swallowed. Please be aware that this takes a few minutes. While the medication is dissolving, the patient will not be able to answer the phone, or the doorbell, or speak very easily. This means that the family will get used to the patient being “out of commission” for a few minutes whenever the regular dose is scheduled.
Storing the medication
If Suboxone is lost or misplaced, the patient may skip doses or go into withdrawal, so it is very important to find a good place to keep the medication safely at home – away from children or pets, and always in the same location, so it can be easily found. It is best if the location of the Suboxone is not next to the vitamins, or the aspirin, or other over-the-counter medications, to avoid confusion. If a family member or visitor takes Suboxone by mistake, he or she should be checked by a physician immediately.
What does Suboxone treatment mean to the family?
It is hard for any family when a member finds out he or she has an illness that is not curable. This is true for addiction as well. When chronic illnesses go untreated, they have severe complications that lead to disability and death. Fortunately, Suboxone-assisted treatment is usually very successful, especially if it is integrated with counseling and support for life changes that the patient has to make to remain “clean and sober.”
Chronic illness means the illness is there every day, and must be treated every day. This takes time and attention away from other things, and family members may resent the effort and time and money that it takes for Suboxone treatment and counseling. It might help to compare addiction to other chronic illnesses, like diabetes or high blood pressure. After all, it takes time to make appointments to go to the doctor for blood pressure checks, and it may annoy the family if the food has to be low in cholesterol, or unsalted. But most families can adjust to these changes, when they consider that it may prevent a heart attack or a stroke for their loved one.
Another very important issue for family members to know about is: addiction can be partly inherited. Research shows that some persons have more risk for becoming addicted than others, and that some of this risk is genetic. So when one member develops opioid addiction, it means that other blood relatives should consider themselves “at risk” of developing addiction or alcoholism. It is especially important for young people who have family histories of substance use problems to know that alcohol or drugs at parties might be dangerous for them, even more than to most of their friends.
It is common for people to think of addiction as a weakness in character, instead of an illness. Perhaps the first few times the person used drugs it was poor judgment. However, by the time the patient is addicted, and using every day, and needing medical treatment, it is definitely more than simply a problem with willpower. In fact, research brain scans that are done on patients with a dependency issue show definite changes. Fortunately, these changes begin to look normal again with treatment.