You can get off of buprenorphine when the time is right without having to experience withdrawal. We began developing a tapering protocol five years ago that we have now perfected. I have made it available to all stable patients desirous of discontinuing buprenorphine. Understand that a percentage of people who are addicted to opiates will be better served with long term maintenance with medication assisted therapy. However, after adequate counseling and implementation of appropriate lifestyle changes: e.g. stable job, stable home environment, stable relationships and the removal of triggers that lead to relapse - our protocol allows motivated patients to be free of ongoing treatment.
Three basic concepts must be understood to implement our protocol. First, buprenorphine is a long acting drug. Second, the brain thinks in percentages and not milligrams. Third, buprenorphine is a very potent drug and (in my opinion) should be dosed in micrograms and not milligrams. It is not possible to explain the entire protocol in this article, however, I will explain each of these three basic tenets.
The half-life of buprenorphine is at least 36 hours. The therapeutic effect is therefore at least 24 hours. Once-a-day dosing facilitates tapering much more easily than split dosing multiple times per day. Therefore, one basic goal before tapering should be to stabilize the patient on once-a-day dosing. The long duration of action of the drug allows for alternating daily dosing such that the brain sees the average of the alternating doses. After a period of at least two weeks of alternating doses it is usually easy to transition to the lower dose every day as the next step and reducing the amount of medication taken per day.
The second and third concepts are illustrated by the fact that when used for pain in opiate naïve patients, buprenorphine is dosed in 25 to 75 µg (That’s MICRO-gram) dosages. The lowest dose form available for treatment of opiate dependency in proprietary products is 2000 µg or 2 mg. Therefore, to reduce the daily dose by smaller percentages it is necessary to use compounded buprenorphine. Reducing one’s dose from 16 mg per day to 8 mg per day is a 50% reduction in dose. This is usually not well-tolerated. Similarly, reducing the dose from 4 mg to 2 mg or from 2 mg to 1 mg is similarly not well-tolerated. Most patients will tolerate a reduction in their dose on a per day basis of up to 15 to 25%, without experiencing significant withdrawal symptoms. The exact schedule for tapering must be individualized and is beyond the scope of this article. Suffice it to say here that patients should be tapered down to between 0.3 and 0.5 mg per day before initiating a protocol of strategic skipping of days as part of the tapering effort.
This protocol works best when closely supervised by a knowledgeable physician monitoring for subtle signs of withdrawal. Clinical evaluation will show when a patient has tolerated a reduction in dose to a given level. Because addicts have frequently experienced severe withdrawal in the past, sometimes, in their zeal to get off medication, they will minimize minor signs and symptoms of withdrawal. When signs are present, sometimes it is better to remain at a given level of dosing for an extra couple of weeks before further tapering. When no signs of withdrawal are present it becomes predictable when a patient will tolerate aggressive further tapering. Patients can be taught how to make as many as two or three adjustments in their dose between monthly visits. Good communication and documentation facilitates adjustment in subsequent prescribed or proprietary or compounded dose forms of the medication when appropriate. Patients interested and learning more about this protocol can schedule a consultation at (770) 559-9554.
** A detailed explanation of this protocol is available for prescribing physicians via email: firstname.lastname@example.org.
Dr. Locke has treated opiate dependent patients for over 10 years. He is a Certified Medical Review Officer, with expertise in interpretation of drug testing. He has served as medical director for Sunrise Detox Facility in Alpharetta since its opening four years ago. His practice interests are varied, but relevant to buprenorphine treatment, he specializes in treatment of opiate addicts who are pregnant. Also, for highly motivated stable patients, his tapering protocol is probably the most unique service he provides.
Author, Thomas J. Locke, III MD
Although Board Certification is not a guarantee of competency, Dr. Locke has accomplished this level of proficiency in 3 different specialties. The process means that your physician and surgeon has received training and passed rigorous written and oral exams to achieve this level of certification. Dr. Locke has been a board certified in internal medicine since 1981. In 1995, by virtue of clinical experience, teaching and other activities as well as passing rigorous written and oral exams Dr. Locke was certified in Emergency Medicine. Frustrated with the traditional insurance billing business model, during the past decade Dr. Locke has focused on innovative services that are not covered by insurance where the only loyalties and obligations are to the patient. Pursuit of these interests has led to also being certified in Aesthetics. He is a member of the American Academy of Aesthetic Medicine, and the American Society of Cosmetic Physicians, The American Society of Lasers in Medicine and Surgery and other professional organizations. His practice philosophy centers on all aspects of personal image enhancement services. Dr. Locke has several hundred hours of extensive training directly from the innovators in the field and professional practice experience in all aspects of body contouring. He has served as an instructor for surgical equipment vendors- teaching doctors in various specialties from all over the country who are learning liposuction, fat transfer and all aspects of body contouring. After more than 1500 cosmetic surgical procedures in the past 6 years under different practice settings his practice is now principally limited to Cosmetic Surgery and a wide array of personal image enhancing services. The surgical practice is 100% devoted to minimally invasive procedures, performed under local or tumescent anesthesia. Unfortunately, in some practices many patients never see their surgeon much until the day of the operation. These offices have nurses and medical assistants or even non-medically trained business people that do most of the evaluation and pre and post-surgical work. Dr. Locke believes that it is important to have the surgeon involved when possible from the very first appointment and throughout all the follow up care. Failure to be able to see or easily speak to the surgeon is a warning sign! You want to be treated like a special patient and not more or less like a number. The doctor insists that his cell phone number is available to all cosmetic surgery patients because it is important for your doctor to be available. Dr. Locke takes great pride in bringing over 30 years of experience caring for complicated medical patients to the current surgical practice. This experience enables him to be comfortable caring for many patients traditionally trained surgeons fear. You are invited to learn more about Dr. Locke’s philosophy and surgical approach by visiting: www.drthomaslocke.com, www.safeofficelipo.com and www.wiselipo.com Other specialty interests include: bariatrics, (weight loss), hormone replacement therapy and anti -aging medicine as well as and addiction medicine. The focus of all activities is improvement in self-image and helping to make the world a better place— helping one person at a time.