Fred Nicolas Thomas III, MD

No- with successful buprenorphine treatment, the compulsive behavior, the loss of control of drug use, the constant cravings, and all of the other hallmarks of addiction vanish. When all signs and symptoms of the disease of addiction vanish, we call that remission, not switching addictions.

The key to understanding this is knowing the difference between physical dependence and addiction.

Buprenorphine will maintain some of the preexisting physical dependence, but that is easily managed medically and eventually resolved with a slow taper off of the buprenorphine when the patient is ready. Physical dependence, unlike addiction, is not a dangerous medical condition that requires treatment. Addiction is damaging and life-threatening, while physical dependence is an inconvenience, and is normal physiology for anyone taking large doses of opioids for an extended period of time.

It is essential to understand the definition of addiction and know how it differs from physical dependence or tolerance.

The American Academy of Pain Medicine (AAPM), American Pain Society (APS), American Society of Addiction Medicine (ASAM), and (NAABT) National Alliance of Advocates of Buprenorphine Treatment, have recognized these definitions below.

1. Addiction
   Addiction is a chronic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
2. Physical Dependence
   Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.
3. Tolerance
   Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.

Physical dependence and tolerance are normal physiology. Addiction is a disorder that is damaging and requires treatment.

When a patient switches from an addictive opioid to successful buprenorphine treatment, the addictive behavior often stops. In part due to buprenorphine’s long duration of action, patients do not have physical cravings prior to taking their daily dose. The drug seeking behavior ends. Patients; regain control over drug use, compulsive use ends, they are no longer using despite harm, and many patients report no cravings. Thus all of the hallmarks of addiction disappear with successful buprenorphine treatment.

Therefore, one is not trading one addiction for another addiction. They have traded a life-threatening situation (addiction) for a daily inconvenience of needing to take a medication (physical dependence), as some would a vitamin. Yes, the physical dependence to opioids still remains, but that is a vast improvement over addiction, is not life-threatening, and it can easily be managed medically. It’s also important to note that the physical dependence pre-existed the buprenorphine treatment and was not caused by it.

Addiction is a brain disease that affects behavior. This addictive behavior can be devastating to the patient and their loved ones. It’s not the need to take a medication that is the problem, many people need to take a medication, but rather it is the compulsive addictive behavior to keep taking it despite doing harm to one’s self or loved ones that need to stop. Whether or not the person takes a medication to help achieve this shouldn’t matter to anyone. If a medication helps stop the damaging addictive behavior, then that is successful treatment and not switching one addiction for another.

Physical connections create pathways in the brain that can be altered when we learn something new. These changes to the brain can be seen with medical imagery. With long-term difficult things like learning to play a musical instrument, these changes can be permanent. Addiction is a learned behavior that changes the brain as well. The brain becomes conditioned to want the substance. Through counseling and other behavioral modification, we can actually, in some cases, change the brain physically. By changing our environment, starting a new job, new hobbies and friends, all will alter our brain in some way. It is possible to undo some of the changes that occurred while addicted. Therapy will recondition the brain closer to pre-addiction status. This will better prepare the patient for a time when they may no longer require medication.

Medication alone can reduce cravings and withdrawal, but recovering from an addictive disorder requires a rewiring of the brain and medication alone is not enough. Attention to eliminating things in life that cause stress or depression will help minimize the chance of relapse. Disassociating with friends who are in active addiction can be difficult but very necessary. An experienced counselor/therapist will be able to teach other techniques that will further help undo some of the brain changes and conditioned learning that occurred while becoming and once addicted.

It is important to find a counselor/therapist that is skilled in treating patients that employ medications in their treatment. Some counselors still dismiss the science behind addiction medicine because they may have been able to successfully end their addiction without it. They sometimes zealously focus on the singular approach that helped them and as a result may not be providing the best care for an individual who may require medication. It pays to find a counselor with a modern evidence-based philosophy of addiction treatment.

Counseling/therapy helps the patient rebuild relationships, repair finances, get a job, assume family responsibilities, decrease stress, anxiety, and depression, and helps the patient make other meaningful changes in their lives that will allow them to achieve and maintain addiction remission.

Per current guidelines, we see clients weekly for the first month. (This is important to closely monitor your response and compliance to the treatment, adjust medications, and observe for any unforeseen side effects.) After the first month of your treatment, our goal is to start seeing you bi-weekly, and eventually monthly if you demonstrate that you are stable on your dose of buprenorphine and confidence in you abstinence from opioids. All treatment plans are personally tailored to each individual patient and your visits will ultimately be at the discretion of your doctor and councilors.

It is recommended to take the first day of treatment off. Some are able to work even on Day One. Certainly, after Day One, you should be able to work with greater attentiveness and clarity than before starting treatment. The transition from addictive substance to Buprenorphine is usually painless and most patients experience no adverse physical effects. In fact, most say that they feel normal again like they were never on drugs at all.

The confidentiality of alcohol and drug dependence patient records maintained by a practice/program are protected by federal law and regulations. Generally, the practice/program may not say to a person outside the practice/program that a patient attends the practice/program, or disclose any information identifying a patient as being alcohol or drug dependent unless:

• The patient consents in writing;
• The disclosure is allowed by a court order, or
• The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or practice/program evaluation.

Violation of the federal law and regulations by a practice/program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.

Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/program or against any person who works for the practice/program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

Buprenorphine is an opioid medication used to treat opioid addiction in the privacy of a physician’s office. Buprenorphine can be dispensed for take-home use, by prescription. This, in addition to buprenorphine’s pharmacological and safety profile, makes it an attractive treatment for patients addicted to opioids.

Read more about Buprenorphine