The partial agonist nature of buprenorphine is behind the usefulness of the drug for treating addiction and chronic pain. Opioid agonists always cause tolerance, and the tolerance usually causes cravings for more and more drug– no matter whether the drug is being used therapeutically or recreationally. Tolerance is unavoidable, at least for now (there are some chemicals that may reduce the development of tolerance, but they are not yet on the market). Buprenorphine, on the other hand, initially results in some level of tolerance, but the tolerance stops at a certain level so that cravings do not occur. The ability of buprenorphine to eliminate cravings for opioids is the basis for its ability to induce remission of opioid dependence.
The Drug Enforcement Agency, or DEA, assigns ‘schedules’ to controlled substances based on the potential for the substance to become a dangerously abused drug. Substances that are ‘Schedule I’ are considered by the DEA to lack medicinal value, and include marijuana, heroin, Quaaludes, psilocybin mushrooms, and LSD. The potent opioid medications and most stimulant medications are Schedule II; there are special barriers to the use of Schedule II medications including the need for written prescriptions, no refills allowed, and limits on prescribing to no more than a 90 day supply. Buprenorphine was classified as a Schedule V substance for a number of years, but was changed to a Schedule III medication around the time that it was approved for use for treatment of opiate dependence. In spite of the higher classification, buprenorphine remains relatively easy to prescribe for physicians and for patients; prescriptions can be called into pharmacies, and refills are allowed. In recent years there has been concern over diversion of buprenorphine and selling of buprenorphine ‘on the street’ for upwards of $20 per tablet. There is some concern by physicians and by patients that the diversion will lead to greater controls placed on the medication; controls that will ultimately become barriers to treatment for some patients.
Remission- Not a ‘cure’
Buprenorphine does not ‘cure’ opioid dependence. When buprenorphine is discontinued, the stimulation of opioid receptors ceases, the neurons with the receptors stop firing, and the craving for opioids returns. Moreover, since buprenorphine does have some agonist activity, discontinuation results in withdrawal—although the withdrawal is usually less-severe than the withdrawal after discontinuation of opioid agonists.
To consider the proper role for buprenorphine and Suboxone a person must understand the ‘medical model’ of addiction. For years there has been a discussion over the role of personal responsibility in addiction, and whether addiction should be considered an ‘illness’ or a manifestation of poor character. I have wrestled with this question myself and have come to a few conclusions. First, addiction fits any definition of ‘disease’ that a person chooses to use. Addiction is progressive; there are familial and environmental influences; the course is quite similar between individuals; the progression of the illness is predictable; and recovery from the illness is possible with appropriate treatment. As for the behavioral component of addiction, most illnesses have a behavioral component. Many diabetics would be cured by weight loss, and many cases of lung cancer or emphysema would be prevented by stopping smoking. So from my perspective, addiction is a disease like any other disease.
The classification of addiction as a disease should not be seen as a way to avoid blame or consequences for criminal or immoral behavior that occurs during active addiction. Every addict is responsible for his or her behavior, regardless of whether the behavior was fueled by addiction! Moreover addicts have a responsibility to keep their addiction in remission as best as possible through the use of proper treatment. Some of the ‘anti-recovery’ literature accuses addicts of using the ‘illness’ label to avoid responsibility– such as ‘I’m not a bad person—I just have a bad addiction’. To be honest though, the anti-recovery crowd need not worry—that type of excuse never gets a person very far!
One final comment on the disease theory: Understanding that addiction is a disease is an important part of ‘getting’ treatment—of being one of those who are successfully treated into sobriety. Understanding the disease nature of addiction allows the addict to accept his powerlessness over the substance, which is the first step in classic twelve step programs. If powerlessness is a disease, the addict can retain a bit of pride during the first step (pride that will be given up later). On the other hand, if addiction is not a disease but a character flaw, the addict is being asked to own and admit to a huge character defect right at the start of treatment. Addiction as a ‘character flaw’ also implies that addiction is shameful. Finally, addiction as a character flaw suggests that a person of ‘good character’ should be able to stop using by simple will power. But will power does not work for addiction for a number of reasons, the most important reason being that if a person thinks he can control his use, he can stop… TOMORROW! That is the addict’s mantra; use today, stop tomorrow. The only real reason to stop using is if a person recognizes the lack of control—and recognizes that using even once will always result in disaster.
Medical management vs. ‘sober recovery’
There is tension between addicts who found sobriety the ‘old fashioned way’ and addicts who choose to use buprenorphine to maintain remission of their addiction. The tension between groups is unfortunate, and needless. The people who worked to establish AA groups a century ago were concerned with saving lives. They were not anti-technology zealots; there are comments throughout the ‘big book’ of AA pointing out that the twelve steps often placed the obsession to drink into remission, even where attempts by medicine and psychiatry had failed. But the emphasis in the AA literature is on the promises—on the fact that recovery from active addiction will result in untold benefits to one’s life. There is no talk of sobriety ‘for sobriety’s sake’; no discussion about the need to be free of all substances, except from the pragmatic perspective that the use of one intoxicant will often lead back to the use of the person’s drug of choice. From my perspective, I look forward to a day when addiction is firmly understood to be a predictable disease, with no more shaming stigma than what is currently applied to those with hypertension or heart disease. In the meantime, I see little value in forced AA attendance for the average patient taking Suboxone. If a person is motivated to approach the twelve step program through his/her own interest and motivation, I think that is fine. My only caveat is to be wary of attempts to push you from Suboxone if you are taking that medication, and to exercise good boundaries. Your medical condition and medical history are your business and between you and your doctor— end of story.