By Kathleen Thompson-Gargano, RN
Kathleen Thompson-Gargano is a nurse and one of the founders of NAABT, Inc. She has been working at Yale University in New Haven, Connecticut, in the field of Buprenorphine research since 1997. The primary focus of Buprenorphine research at Yale has been to find the best way to take this state-of-the-art treatment for opioid addiction, into the privacy of a doctor’s office and primary-care setting. Kathleen’s role in these studies has provided her with an opportunity to counsel and work closely with hundreds of patients. Below are recommendations, advice, and explanations of what to expect when starting Buprenorphine treatment.
Preparation is everything.
Your doctor or his/her staff will instruct you on how to prepare for your first visit. We recommend that you educate yourself as much as possible before hand.
You should expect the first day of treatment to take about two hours. It is probably best if you don’t work that day. Your doctor will prescribe approximately 8 mg to 16 mg on the first day.
It is imperative that you be in withdrawal before taking your first dose of Buprenorphine. If you are not, you could experience severe withdrawal symptoms. This would cause you to think that the medication doesn’t work.
Why? Buprenorphine is much stronger at the brain’s receptor sites than any other opiates – such as heroin, painkillers, or methadone. This means that some Buprenorphine will be used to throw the other opiates off the sites causing the experience of violent and rapid withdrawal. Then there may not be enough buprenorphine left to re-occupy the opiate receptor sites. This is called precipitated withdrawal. If you are already in mild withdrawal, many receptor site are empty so most of the buprenorphine can be used for occupying them and little wasted on expelling other opiates.
Do not fool yourself. There is no way around the fact that you must be in mild to moderate withdrawal before taking Buprenorphine for the first time.
Another reason to be in withdrawal is that it is one way for the doctor to determine what your proper dose should be.
Expected doctor visits:
This is up to your doctor. Most doctors will want to see you at least twice in the first week and at least once a week until you are confident in your ability to take the medication correctly, and until your doctor is confident that the right dose has been achieved for you. There are other things that must be accomplished early in treatment such as finding a counselor and doing lab work.
Your doctor should know which pharmacy has Buprenorphine. Some doctors will dispense the medication from their practice. This is a little more complicated for them so not all will be able to do so.
Urine toxicology will likely be done before you begin treatment to check for all substance use, and then periodically, perhaps randomly, thereafter.
How you will feel during the first week:
It is normal to feel uncertain about whether the medication will really eliminate or at least minimize withdrawal symptoms. You will soon learn that it does work. But there is still work for you to do. Continued drug misuse will mean that you will never feel quite right because your brain receptor sites will not be allowed to fully calm down. They will be tossed in and out of some level of withdrawal. If taken properly you will feel normal by the end of the first week. Some patients say they feel like they did before they ever did drugs.
When you will be able to work:
To ensure maximum comfort for yourself, try to take the first day of treatment off. After that you should be fine to return to work, even if your job is physical in nature.
If you have a history of sleep problems prior to your drug misuse, you may have them again after starting Buprenorphine treatment. Most patients report that they sleep well almost immediately. If you find that you are wide awake at night it may be that you are taking your medication too close to bedtime.
Families are deeply affected by the addicted family member. They find it difficult to trust and believe them. They have often been let down or neglected by the person who was totally fixated on finding, paying for, and misusing drugs.
Remember; if they are still in your life at this point they have been patient with you.
Most likely they have never stopped loving you, but they have stopped trusting you. It takes time, faithfulness, and patience to regain trust. Give them as much of your patience, time, and honesty as you can and talk about this with your counselor. Remember; if they are still in your life at this point they have been patient with you. You may know you are going to remain abstinent, but they have to go by past experiences.
One of the most important things you will do early in treatment is to distance yourself from any friends that are still misusing substances. Even if you can spend time with them and NOT use, the moment will come when you give in. Regardless of how strong you feel you are, the constant temptation keeps your thoughts on drugs. You cannot resist drugs without thinking about them. It is better to be in a situation where the idea of drugs does not even come up. You must put the odds in your favor and eliminate as much risk as possible.
A genetic predisposition to risky behavior does not alone account for drug misuse and addiction. Take advantage of counseling to learn all you can about what makes you tick and what ticks you off. Develop strategies with your counselor for handling the inevitable stress of life. NA and AA call this “learning to live life on life’s terms.” This is a necessary skill for all human beings.
People with addictions quickly train themselves to be short-term thinkers. For example they take their needs one day at a time – where to get the drugs, where to get the money for the drugs, and how to prevent withdrawal. Counseling will help you learn to be a long-term thinker again. If your substance misuse began as a teenager or younger, long-term thinking and planning may be a skill you have never developed. Thinking in terms of short-term, medium- term and long-term goals is incredibly rewarding. Ask your counselor to help you develop strategies so that you can do this in your life.
Counseling is about rebuilding your life. It helps give you the tools and strategies you need to remain happy and healthy. When most people finally seek treatment they feel defeated, the addiction has defeated them, not only physically but defeated economically and socially as well. Counseling helps you restore and rebuild .
Some patients find it very helpful to attend AA or NA meetings. This gives them the understanding and support they need. You may find that it is difficult to find the group that will work for you. Go to several meetings until you find the one that will best suit your needs. If they are against the use of medication to maintain sobriety, either find a different group, educate them about the fact that addiction is a brain illness like any other illness, or just don’t share that particular part of your story.
Remember, Buprenorphine is a new, cutting-edge treatment and not everyone has heard of it yet. The fact that addiction is a brain illness and not necessarily a sign of moral depravity or character weakness is, in itself, a new concept. Many help groups do not modernize their thinking as addiction science progresses.
Taking your medication:
In most cases it is best to take your full dose of medication at the same time every day. There are a couple of reasons for this.
1.) Soon you will feel so normal that it will be easy to forget to take your medication. Therefore we recommend that you take your Buprenorphine at a time, usually in the morning, when you can have time to be quiet and undistracted. For example, get up in the morning, have a glass of orange juice, take your medication and let it dissolve while you read the paper, or take a shower, or drive to work. The important thing is to do it at the same time, full dose, and do not talk or swallow until it is fully dissolved.
2.) Splitting your dose over the course of the day provides more opportunity to forget and reinforces old behaviors.
3.) Some people find that they have increased energy after taking Buprenorphine. It may last for a couple of hours. This can make it difficult to sleep at night. In that case it is better to take your dose in the morning or mid-day.
The exceptions to this rule may be:
Some patients will be advised to split their dose during the day because it helps them to better manage their symptoms. One of the great things about Buprenorphine is the ability to customize the dose and administration. Your doctor or nurse will be able to help you find the best answer for you.
The first feelings you will have on the first day of treatment will be at least the first three symptoms of withdrawal that are unique to you. They may be sweats, restlessness, anxiety, agitation, chills, stomach cramps, etc. This is good!! It means you will have a good experience and relief is just around the corner!
Twenty to thirty minutes after your first dose of at least 4 mg you will begin to feel those symptoms go away. You should be given a second dose approximately an hour later. After another 4 mg to 8 mg you will be very comfortable. Some doctors dose generously the first day or two. This will allow you to feel what is often described as “normal” in the first hour or so.
Occasionally we see patients who believe that they are completely cured in the first week or so, because for the first time in years they feel normal every day and night. It is the medication that is making it possible to feel this way. Do not be hasty to get off of the medication. Opioid addiction is a brain disease. It is manageable because you can make the symptoms go away with Buprenorphine, but the disease itself does not go away that fast.
What Can I Expect on Day 1?
You will need to be in at least mild to moderate withdrawal. This means you will have dilated pupils, sweats, chills, nasal stuffiness, watery eyes, irritability and possibly stomach cramps and diarrhea. More specifically, you will have the first few symptoms that are unique to you. Do not take the medication until you are certain you are in at least mild to moderate withdrawal. Tell your doctor what is typical for you when you are experiencing withdrawal.
You will learn how to take sublingual medication, which means medication that is taken under the tongue. There are large blood vessels under the tongue that give direct access to the bloodstream because there is only a very thin layer of skin covering those vessels. Relief of withdrawal symptoms is achieved quickly when this medication is administered under the tongue. It is less than 20% effective when swallowed and may even cause nausea. Take the time to learn how to take it properly. The taste is bitter so it may be useful to have a bottle of juice, soda, or some hard candy available to take after the medication is dissolved.
You will be given pills to take home or a prescription for take-home medication. You will need to take your medication the same time every day, and the full dose each time, unless your doctor has a reason to have you take it differently.
You will probably sleep very well the first night and the nights thereafter. The exception is if you have a history of sleep problems.
You will receive your appointments for subsequent visits. You will be given information to read that is specific to being a patient in that practice.
You will begin to experience an increased confidence in how to take your medication and in the ability of Buprenorphine to make you feel better.
You should be able to return to work.
You will be actively working toward avoiding the people, places, and things that make you think about using.
You will need to continue actively working toward avoiding the people, places, and things that make you think about using. You will notice the medication working. By Day 5 you should feel normal, like you did before you started using drugs.
You may be experiencing the “honeymoon” stage of your recovery. You will have a sense of hopefulness because you feel like you are in control and all is well again.
Do not become so comfortable that you become lax in your routine of medication administration. Take your Buprenorphine in the fully prescribed dose at the same time every day unless your doctor has instructed you otherwise.
This is often the week some patients test the blocking effect of the Buprenorphine. They use drugs to see if it really blocks the effects, or just reduce them as with methadone. Whether you test it out yourself or learn from other’s mistakes, the result is the same. The Buprenorphine completely blocks other opioids and not only do you relapse but you receive no high and waste the money spent on drugs. Once you realize this, you find you no longer need to constantly debate between use and sobriety. If you wanted to use, you would have to be off the Buprenorphine for at least 3 days. Hopefully you would have one strong moment in that time, and take your Buprenorphine.
Keep your counseling appointments and make the most of them.
Old drug using friends may start to come around thinking that by now you are ready to come back to your old ways. It is important to be strong now, and although it is easier to do so on Buprenorphine, it still will not be “easy”. Stand firm. When they see your success you may be able to help them to find the same way out. Some people will never quit using. Needless to say, their lives will be shorter than they have to be.
Perhaps it has been difficult for you to get a job or solve a relationship problem. It may become difficult to remain optimistic now that a month has gone by. Work with your counselor to make small goals and accomplish them so that you don’t lose heart. Many bridges can be burned with prolonged drug use. It may take quite a while to recapture your relationships and financial stability.
Months 2 and 3
You will be comfortable about taking your medication by now. You should expect to have a well-established routine with regard to doctor appointments, counseling appointments and taking your Buprenorphine at the same time every day.
Like most other patients you will just feel normal.
Problems that came into existence due to drug use may be a tough reality to face. Face them anyway and you will know what it is like to be successful and strong in adversity. This will be a skill you will be glad you have, over and over again.
Buprenorphine Maintenance (Months 4 +):
Due to the 30/100-patient limit and the physicians’ desires to help as many patients as possible, some doctors don’t want to keep patients on maintenance therapy with Buprenorphine. Studies show that the longer you are on the medication, the better your chance or permanent abstinence.
Patients often know when they are ready to start decreasing their medication dose. It is best to gradually reduce your dose when you are ready to stop Buprenorphine treatment. For example, reduce your dose from 16 mg to 14 mg for a month, and then reduce again by 2 mg each month. If you find your symptoms are beginning to return go back up 2 mg.
After several months of treatment patients rarely feel a difference when they decrease their dose by a few milligrams.
Alternative Treatments for Remaining Abstinent
Taking this blocker medication is an option when Buprenorphine treatment is discontinued. It will make it impossible for you to fell euphoric if you do take opioids. Unlike Buprenorphine, it does so without taking cravings away. Therefore, if you really feel overwhelmed by cravings and stop taking Naltrexone you will be able to get high again. Some patients refer to the difference Buprenorphine makes as “keeping them protected” because they claim they “don’t even think about drugs anymore”.
Some find it helpful to attend abstinence-based meetings such as Narcotic Anonymous, Alcoholics Anonymous, or church-based meetings.
It is very beneficial to engage in counseling to determine why you began abusing drugs in the first place. If those issues are not addressed the chronicity of drug misuse is reinforced at the expense of your long-term recovery
An experienced drug counselor will help you develop strategies that will work best for you in terms of making your recovery permanent.
“Prior to my research work at Yale, I held all of the stereotypical assumptions about opioid addicted people. You know, the homeless, IV heroin addict living by the dumpster. That stereotype marginalizes far too many people right out of any hope for recovery. The fact is, I have yet to meet even one patient who actually fits the stereotype.
Research has proven that opioid addiction is a brain disease. Our cultural paradigm imposes a punitive and moral standard on addiction because we are unaware of what addiction is and why certain people become addicted while others do not. The fact that anyone could get to such a state of desperation and rejection is a sad statement about our society.
Buprenorphine treatment for individuals, who want recovery, means freedom from the enslaving clutches of addiction. Ask anyone who has been there. Addiction is a full time job. My patients describe it as a vicious cycle of getting money to get drugs, to avoid the agony of withdrawal. Anyone who wants to get their life back should be able to find hope from those of us who have dedicated our professional lives to saving the lives of others.
It needs to be said that not everyone in our studies has achieved complete abstinence from substance abuse. However, many have! And they are now fully involved parents, family members, business owners, and productive citizens in their communities. The privilege of seeing these precious people set free from their addiction and allowed to become who they were meant to be, has been the most rewarding part of my nursing career.
I would encourage all physicians and nurses to seize the opportunity to save a life in this way. It is why we chose our noble professions in the first place.
Buprenorphine is without a doubt, an effective, dignified, and private treatment option for the opioid dependent patient who wants both treatment and a return of their self esteem.
Thus the passion and purpose shared by all of us here at NAABT. We are dedicated to our mission which is to facilitate getting this treatment opportunity to as many people as possible.”
-Kathleen Thompson-Gargano RN
To suppress the debilitating symptoms of cravings and withdrawal, enabling the patient to engage in therapy, counseling and support, so they can implement positive long-term changes in their lives which develops into the new healthy patterns of behavior necessary to achieve sustained addiction remission. - explain -