Why is it so hard for some people to quit opioids and start Suboxone?
Usually, when you go to a Suboxone doctor to quit opioids, such as pain pills or heroin, your doctor makes you wait before you can start Suboxone. First, you must stop taking opioids. Then, you have to wait until you have opioid withdrawal symptoms.
The period of waiting from your last opioid use until the time when you can take your first dose of Subutex or Suboxone is typically about 18 to 24 hours. If you are taking a longer-acting opioid, you may have to wait longer, possibly even several days.
The purpose of this waiting period is to avoid precipitated withdrawal (PW). One of the drawbacks of buprenorphine, the main ingredient in Suboxone, is that it can cause you to go into a severe opioid withdrawal syndrome if you take it too soon.
While this waiting period of one day, or even several days, may not seem like a long time, it can feel like an eternity to someone who is trying to quit opioids. As a result, many people relapse and go back to using opioids again before even getting started on Suboxone.
What makes Suboxone induction so difficult for some people?
Induction is the name for the waiting period from quitting opioids until it is time to take the first Suboxone. Suboxone induction also includes the period afterwards when the doctor works with the patient to figure out the best effective dosage of Suboxone.
When it comes to heroin, drug dealers and clandestine labs are now cutting heroin with fentanyl and synthetic designer fentanyl analogs. It is rare to find real, pure heroin on the streets anymore.
Unfortunately, the properties of these designer drugs, synthesized to target opioid receptors, can be unusual, and very different from naturally derived opiates and opioids. Hence, heroin from the streets can linger in your system, making the Suboxone induction process more difficult.
Some heroin users report having precipitated withdrawal when they start buprenorphine or buprenorphine/naloxone even days after stopping heroin use. As a result, they often go back to using heroin again, discouraged by the withdrawal sickness caused by trying to start Suboxone.
Precipitated withdrawal is usually not dangerous, but it is extremely uncomfortable.
Precipitated Withdrawal can be very uncomfortable for new Suboxone patients, trying to quit heroin. Some even describe it as the worst they have ever felt.
Suboxone doctors want their patients to have a successful Suboxone induction. They closely monitor their patients, waiting until they are in a state of moderate withdrawal by the clinical opiate withdrawal scale (COWS) before starting buprenorphine treatment.
The process of induction usually goes smoothly, with the patient being told what to expect. When street heroin, contaminated with fentanyl and opioid analogs, is involved, the induction process can be derailed when the patient unexpectedly goes into precipitated withdrawal.
It is important to keep in mind that precipitated withdrawal, and opioid withdrawal in general, is not typically physically dangerous. As uncomfortable and unpleasant as it is to feel the sickening chills, cold sweats, aches and cramps of opioid withdrawal, it rarely causes any serious health problems.
The worst consequence of withdrawal is when it causes a patient to return to dangerous opioid use. Even worse is when a patient is discouraged from trying Suboxone treatment again in the future because of a bad experience with precipitated withdrawal.
What is the Bernese Method and how can it help me quit opioids?
In other countries around the world, Switzerland and Canada for example, there have been novel approaches to opioid addiction treatment. While in the US, doctors are restricted to only using two opioids to treat opioid addiction, methadone and buprenorphine, these countries are using treatment protocols with other opioids, including heroin.
The benefit of putting someone who is abusing street heroin on medical heroin is that the patient is now getting a known drug at a known dosage under the care of a doctor. Prescription heroin programs have had significant success in Canada and Switzerland.
Another advance in these countries is the use of supervised consumption sites, where heroin users can use drugs obtained on the street in a supervised area. Canada even has biometric dilaudid dispensing machines on the streets to provide a safe source of opioids for approved opioid addicted people.
The Bernese Method is an alternate method for Suboxone induction that doctors use to avoid the discomfort of precipitated withdrawal. Canadian medical journals have described the Bernese Method in detail, referring to it as Suboxone micro dosing.
How could the Bernese Method help me to quit street heroin?
If you have been through the experience of going to a Suboxone doctor for treatment and having Suboxone put you in precipitated withdrawal, you know how unpleasant it can be. Recently, precipitated withdrawal has become more of a problem with the unusual exotic mix of synthetic opioids found in heroin.
Some better known heroin additives are gray death and U-47700, also known as pink heroin. It is likely that here is an even greater variety of long-lasting opioid analogs on the streets, masquerading as heroin, that we are not yet aware of.
The Bernese Method is a buprenorphine protocol that offers a possible solution to the difficult and rocky road of Suboxone induction for patients trying to quit heroin. The idea is that the patient is given a very small dose of buprenorphine/naloxone (Suboxone) during the time that they are still using heroin or other opioids. This small dosage of buprenorphine could be as low as 0.25 mg or even lower.
While Suboxone usually causes precipitated withdrawal when given too soon after opioid use, very small doses of Suboxone will not cause as much of a problem, especially if the user has not yet quit their regular opioid use. As per the Bernese Method, the doctor will gradually increase the Suboxone dosage. Within a short time, the patient will be able to quit opioids without having to worry about precipitated withdrawal.
How does giving a microdose of Suboxone together with another opioid work?
If you are familiar with how the buprenorphine in Suboxone works, you may find it unusual that there is any way to combine Suboxone with another opiate or opioid, such as heroin or fentanyl. Buprenorphine is a potent opioid receptor blocker and a partial opioid agonist. The half-life of buprenorphine is much longer than most other opioids.
The general understanding of how bupe works is that, if it is taken with another opioid, it displaces that other opioid, causing immediate precipitated withdrawal. On the other hand, if another opioid is taken during established Suboxone therapy, it should have little or no effect, because the receptors are blocked.
In reality, the situation is a bit more nuanced. The percentage of opioid receptors blocked when Suboxone is given depends on the dosage. It is possible to take buprenorphine and another opioid at the same time when the buprenorphine is at a sufficiently low enough dosage.
Pain doctors are already experienced in microdosing buprenorphine.
For example, there is Butrans, a buprenorphine weekly dermal patch prescribed for chronic pain. The patch releases buprenorphine into the patient’s system in microgram doses. Because of the very low dosage of buprenorphine given with Butrans, doctors can still prescribe opioid tablets to their patients for breakthrough pain.
Another example involves when a Suboxone patient has a medical emergency requiring acute pain management. The perception of many patients is that any opioid given to them in the hospital will pass right through their system because buprenorphine has blocked all the receptors. In reality, there are still plenty of available opioid receptors for pain medication to work in emergency situations. It may be less effective, but it can still provide adequate pain relief.
As you can see, microdosing of buprenorphine to transition patients through induction and on to Suboxone may be a viable option. Microdosing of buprenorphine is already being used in the field of pain management in the form of Butrans. There is also a buprenorphine buccal film named Belbuca, dosed in microgram strengths, that is prescribed for chronic pain.
Belbuca’s FDA approved prescribing information recommends that doctors consider rescue medication for patients with breakthrough pain. This means giving another opioid with the microdosed buprenorphine contained in Belbuca.
Could The Bernese Method be used in the United States?
Currently, the best option for many people who have difficulty starting Suboxone, is to go to a methadone clinic. Unfortunately, once a patient is put on methadone, it can be difficult to transition from methadone to Suboxone in the future. Methadone has a high success rate, partly because it can be started immediately, without any waiting time for the patient to go into withdrawal. There is no risk of precipitated withdrawal from methadone.
American Suboxone doctors will likely not feel comfortable using The Bernese Method because it involves instructing the patient to take Suboxone and their opioid of abuse at the same time. Doctors are uncomfortable with the idea that it may appear that they condone ongoing street drug use.
However, in many cases, patients who are new to the Suboxone clinic will have a negative experience with precipitated withdrawal and go back to the streets for opioids regardless. Suboxone doctors are aware that this is happening because these patients will often return to report on their treatment failure, hoping to try again to quit opioids.
Possibly, doctors could recommend to patients that, while relapse on opioids is dangerous and not recommended, if they do go back to using opioids, they should continue taking daily Suboxone at a low, but steadily increasing dosage. The doctor would not be recommending, or even condoning, illicit opioid use.
They would only be acknowledging the fact that patients sometimes struggle with Suboxone induction and relapse. By giving the patient instructions for what to do if this happens, doctors may be able to retain more patients in treatment, leading to more successful outcomes.
What is the microdosing schedule for the Bernese Method?
There are different dosing schedules for using the Bernese Method during the Suboxone induction time. Some recommend starting at 0.2 or 0.25 mg daily, steadily increasing to at least 12 mg. Others start at 0.5 mg daily. While we do not have FDA-approved versions of Suboxone available with less than 2 mg of buprenorphine, it is possible for patients to divide a 2 mg dose into two or even four equal parts.
Another possibility is to use buprenorphine microdoses created by a compounding pharmacy. Compounding pharmacists can produce buprenorphine troches in doses as low as a quarter of a milligram, or even a sixteenth of a milligram.
Suboxone doctors have an opportunity to not only employ a modified version the Bernese Method for patients, but they may also improve on it by starting patients at even lower dosages, using specially formulated buprenorphine compounds. Doctors do not have to condone ongoing drug use, but they can acknowledge that it is a fact of life that some patients are going to relapse early on.
Harm reduction means that we provide protection to people who continue using drugs.
Making naloxone, the overdose reversal rescue drug, more available is a form of harm reduction. Clean needle and syringe exchange programs and supervised consumption sites are another example of harm reduction. These programs acknowledge that people are sometimes not ready to quit, but it is still worthwhile to protect their health and provide a safer environment for them.
We might think of The Bernese Method as another form of harm reduction. Doctors can start their patients on a Suboxone program and acknowledge that not all patients have a smooth transition away from opioids.
Relapses happen, but they do not have to end in failure or tragedy. Patients should be able to count on the support of their doctors to see them through the Suboxone induction process with additional tools for success.
Doctors are already prescribing harm reduction tools to their patients.
If you are a Suboxone doctor and you are uncomfortable with the idea of The Bernese method of microdosing Suboxone while a patient may still be continuing heroin use, here is a way to think about it. Are you already prescribing naloxone nasal spray to your new patients?
Most doctors who prescribe Suboxone around me, in my community here in South Florida, also give their patients a prescription for Narcan, an emergency overdose rescue drug. Why prescribe Narcan to a patient who is starting Suboxone treatment? Aren’t you planning for your patient to have success in their medication-assisted treatment?
Ideally, if a patient start Suboxone and stays on treatment long-term, without relapse, there should be no need for Narcan. However, we, as doctors, accept the reality that Suboxone treatment does not always start out with a perfect record of success for every patient. Narcan is important, because some patients will relapse early in treatment, so it is a reasonable precaution to have Narcan in the home.
Similarly, when patients start at a Suboxone clinic and then relapse after an episode of precipitated withdrawal, doctors have an opportunity to give those patients a contingency plan with this novel Suboxone protocol. Continued opioid use is not part of the medical plan provided by the doctor, but the doctor can give the patient a plan for how to proceed with Suboxone therapy if relapse does happen.