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 who want to discontinue buprenorphine. Understand that a percentage of people who are addicted to opiates will be better served long-term by medication assisted therapy. However, after adequate counseling and implementation of appropriate lifestyle changes — 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.
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, not milligrams. It is not possible to explain the entire protocol in this article, but 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 tapers much more easily than split dosing multiple times per day. Therefore, one basic goal before tapering should be to stabilize the patient on one dose each day. The long duration of the drug’s action 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, meaning that the amount of daily medication is reduced.
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 in MICRO-grams) dosages. The lowest dose available for opioid treatment 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. The body doesn’t tolerate this change very well. Similarly, reducing the dose from 4 mg to 2 mg, or from 2 mg to 1 mg, is not well-tolerated. Most patients will tolerate a reduction in their dose on a per-day basis of up to 15-25%, without experiencing significant withdrawal symptoms. The exact schedule for tapering must be individualized and is beyond the scope of this article. Suffice to say, patients should be tapered down between 0.3 and 0.5 mg per day before initiating 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 tolerates a dose-reduction to a given level. Because addicts have often experienced severe withdrawal in the past, sometimes, in their zeal to become unmedicated, they will ignore minor signs of withdrawal. When signs are present, sometimes it is better to remain at a given dose-level for an extra couple weeks before further tapering. When no signs of withdrawal are present, it becomes likely when a patient will tolerate further tapering. Patients can be taught to make as many as two or three adjustments in their dose between monthly visits. Good communication and documentation facilitates these adjustments in later dose forms of the medication when appropriate.
Dr. Locke has treated opiate-dependent patients for over ten 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, GA, since its opening four years ago. His practice interests are varied, but regarding buprenorphine treatment, he specializes in treating opiate addicts who are pregnant. Also, for highly-motivated and stable patients, Dr. Locke’s tapering protocol is his most unique service.
Although Board Certification does not guarantee competency, Dr. Locke has accomplished this level of proficiency in three different specialties. Namely, he has received training and passed rigorous written and oral exams to achieve this level of certification. Dr. Locke has been 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 became certified in Emergency Medicine. Frustrated with the traditional insurance-billing business model, 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 his certification in Aesthetics. He is a member of the American Academy of Aesthetic Medicine, the American Society of Cosmetic Physicians, and the American Society of Lasers in Medicine and Surgery among others.
Dr. Locke’s practice philosophy centers on all aspects of personal-image enhancement services. He has several hundred hours of extensive training directly from the innovators in the field, as well as professional experience practicing all aspects of body contouring. He has served as an instructor for surgical equipment vendors—teaching doctors from all over the country who are learning liposuction, fat transfer and other areas of body contouring. After more than 1,500 cosmetic surgical procedures in the past six years, his practice now principally performs Cosmetic Surgery and a wide array of personal image enhancing services. The surgical practice fully supports minimally-invasive procedures, performed under local or tumescent anesthesia.
Unfortunately, some practices prevent their patients from seeing their surgeon until the day of the operation. These offices have nurses, medical assistants, or even non-medically trained business people do most of the evaluation and pre- and post-surgical work. Dr. Locke believes it is important to involve the surgeon from the very first appointment through the follow up care. Lack of access to the surgeon is a warning sign! You should be treated like a special patient and not like a number. The doctor insists that his cell phone number is available to all cosmetic surgery patients, because your doctor should be available to you. Dr. Locke takes great pride in bringing more than 30 years of experience caring for complicated medical patients. This experience enables him to be comfortable caring for many patients whom traditionally-trained surgeons would fear. Other specialty interests beyond addiction medicine include bariatrics (weight loss), hormone replacement therapy, and anti-aging medicine. All these activities emphasize improved self-image and improving the world one person at a time.