Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Allow patients to continue their opioid of choice while starting microdoses of buprenorphine

Julie Craig, MD
Meds
June 16, 2022
Share
Tweet
Share

Twenty-six hours into the shakes, sweats, crawling anxiety, and gripping nausea of opioid withdrawal, Faye caves in and takes a couple of fentanyl tabs. She knows that she must tough out a couple of days without fentanyl to start Suboxone (buprenorphine/naloxone) through a medication-assisted treatment program, but the sickness gets the better of her. Those couple of tablets reset the clock on her withdrawal.

Starting buprenorphine – an evidence-based lifesaver for opioid-dependent individuals – traditionally requires a substantial withdrawal period so that the tightly binding partial agonist does not quickly displace the pure opioid and cause sudden severe precipitated withdrawal. However, as far back as 2010, researchers in Switzerland experimented with a technique that came to be known as the Bernese method, where patients continue their opioid of choice while starting microdoses of buprenorphine that gradually increase over the span of a week, eventually displacing the opioid and leaving the patient on buprenorphine alone.

As fentanyl arises as a cheap replacement for bulkier products like oxycodone and heroin, this method has become ever more crucial as many patients are simply unable to tolerate fentanyl withdrawal long enough to initiate even a couple of milligrams of buprenorphine. Microdosing induction allows people to start buprenorphine while continuing their lives without stigmatizing interruptions to work, school, childcare, and life at large that are often caused by the opioid withdrawal period. It is entirely possible that forcing people through prolonged withdrawals to start buprenorphine was never necessary, perhaps even a needlessly cruel barrier to those trying to enter into recovery. Microdosing induction might have been the better tactic all along.

At the same time, microdosing induction to buprenorphine underlines a contradiction inherent in drug war-era rules and regulations. While avoiding the intensive withdrawal period, this induction technique requires that individuals continue their opioid of choice for approximately seven days while titrating buprenorphine to an effective dose. Unless the patient has an opioid prescription for pain, these continued opioids must come from illicit sources due to a law called the Harrison Narcotics Tax Act. The mundane language of the act – that doctors only prescribe opioids within the course of their usual practice – was interpreted by courts to mean that doctors could not prescribe opioids to assist an addicted patient, as addiction was not classified as a disease but a moral failing and thus not within the physician’s purview. As such, American physicians cannot prescribe safe, pharmaceutical-grade opioids to assist patients during the seven-day microdose transition to buprenorphine. Patients must secure their own opioids, which raises predictable barriers: paying to obtain more illicit opioids when individuals may have diverted funds to pay for treatment itself, reaching out to a dealer they have already tried to dislodge from their lives, engaging in the triggering behavior of continuing illicit substances when they have decided to quit, and risking overdose from an increasingly unpredictable and contaminated street supply.

This legal framework arose before nearly all modern understandings of substance use disorders, predating the founding of Alcoholics Anonymous by two decades, preceding the approval of methadone for opioid use disorder (OUD) by thirty years, and antedating the legal approval to use buprenorphine in the treatment of OUD by over eighty years. Indeed, the foundational legal structure under which addiction medicine operates today was passed by congress the same year that Archduke Franz Ferdinand was assassinated on the streets of Sarajevo.

Compounding the problematic legacy of the 1914 law is the comparatively youthful Controlled Substances Act, passed under President Nixon’s guidance in 1970. Among its crowning achievements is the classification of cannabis as a Schedule I substance “with no currently accepted medical use and a high potential for abuse,” setting the stage for the mass incarceration wave that continues today even as a plurality of states moves to legalize the substance. To write buprenorphine, providers are granted an exception to the Controlled Substance Act with the “X-waiver,” a bureaucratic innovation that simultaneously defies the spirit of the Harrison Act and limits buprenorphine provision to a set number of patients per provider in a manner never applied to problematic substances like prescribed benzos and stimulants.

Under a saner and more humane legal regime, Faye (a fictional composite of everyday cases) would enter into treatment with a provider who can assess her current dose and then prescribe sufficient pharmaceutical-grade oral opioids under close supervision to stave off withdrawals. Microdoses of buprenorphine would be initiated and cautiously increased over whatever time period is needed for the buprenorphine to exert its dominance at the opioid receptor while she remains comfortably free from withdrawal symptoms. To accomplish this humane end, American drug policy would require a revamp that honors a hundred years of discovery on the biochemistry of receptor-ligand dyads, the neurobiology of adverse childhood events, and the innovation of statistical methods to evaluate evidence and formulate best-practice recommendations. Most of all, Americans deserve the freedom and autonomy to choose the medical pathway most appropriate to their needs without the punishing risk of overdose while making the transition to recovery.

Julie Craig is an addiction medicine specialist.

Image credit: Shutterstock.com

Prev

Virtual care is convenient, but is it better for everyone? [PODCAST]

June 15, 2022 Kevin 0
…
Next

Is there more to patient safety than preventing medical error?

June 16, 2022 Kevin 0
…

Tagged as: Pain Management

Post navigation

< Previous Post
Virtual care is convenient, but is it better for everyone? [PODCAST]
Next Post >
Is there more to patient safety than preventing medical error?

More by Julie Craig, MD

  • The promises and limits of a fentanyl vaccine

    Julie Craig, MD
  • We must disrupt harm

    Julie Craig, MD
  • The complications of drug regulation

    Julie Craig, MD

Related Posts

  • Cutting the red tape with buprenorphine treatment for opioid use disorder

    Christina Kinnevey, MD
  • Are patients using social media to attack physicians?

    David R. Stukus, MD
  • Doctors and patients continue to search through the overgrown forest of corporate health care

    Michele Luckenbaugh
  • Don’t let the opioid crisis affect the treatment course for your patients

    T.J. Matsumoto, PA-C
  • You are abandoning your patients if you are not active on social media

    Pat Rich
  • Do we really have a choice in health care?

    Cary Fitchmun, MD

More in Meds

  • The real cause of America’s opioid crisis: Doctors are not to blame

    Richard A. Lawhern, PhD
  • Can personalized medicine live up to its hype in health care?

    Ketan Desai, MD, PhD
  • The effects of the nationwide stimulant shortage on a private psychiatry practice

    Christine Tran-Boynes, DO
  • Why North American medical cannabis can’t compete globally

    Michael Sassano
  • How were we duped and what can we do about the opioid overdose crisis?

    Ronald A. Zent, MD
  • Caught in the middle: How health insurance companies influence cancer drug selection

    Paul Pender, MD
  • Most Popular

  • Past Week

    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • From physician to patient: one doctor’s journey to finding purpose after a devastating injury

      Stephanie Pearson, MD | Physician
    • Breaking the cycle of misery in medicine: a practical guide

      Paul R. Ehrmann, DO | Physician
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Why are doctors sued and politicians aren’t?

      Kellie Lease Stecher, MD | Physician
  • Recent Posts

    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • From rural communities to underserved populations: How telemedicine is bridging health care gaps

      Harvey Castro, MD, MBA | Physician
    • 5 essential tips to help men prevent prostate cancer

      Kevin Jones, MD | Conditions
    • Unlock the power of physician compensation data in contract negotiations [PODCAST]

      The Podcast by KevinMD | Podcast
    • From pennies to attending salaries: Why physicians should teach their kids financial literacy

      Michele Cho-Dorado, MD | Finance

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • At-Home Topical Therapy for Molluscum Contagiosum Gets High Marks
  • Senators Press Moderna's CEO to Drop COVID Vaccine Price
  • Senators Press HHS Chief on Alzheimer's Drugs, Opioids at Budget Hearing
  • Despite Abortion Restrictions, Ob/Gyn Remains Competitive Residency
  • Cholera Outbreak Widens; What Beethoven's DNA Revealed; Grindr's Free HIV Tests

Meeting Coverage

  • At-Home Topical Therapy for Molluscum Contagiosum Gets High Marks
  • Outlook for Itchy Prurigo Nodularis Continues to Improve With IL-31 Antagonist
  • AAAAI President Shares Highlights From the 2023 Meeting
  • Second-Line Sacituzumab Govitecan Promising in Platinum-Ineligible UC
  • Trial of Novel TYK2 Inhibitor Hits Its Endpoint in Plaque Psoriasis
  • Most Popular

  • Past Week

    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • From physician to patient: one doctor’s journey to finding purpose after a devastating injury

      Stephanie Pearson, MD | Physician
    • Breaking the cycle of misery in medicine: a practical guide

      Paul R. Ehrmann, DO | Physician
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Why are doctors sued and politicians aren’t?

      Kellie Lease Stecher, MD | Physician
  • Recent Posts

    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • From rural communities to underserved populations: How telemedicine is bridging health care gaps

      Harvey Castro, MD, MBA | Physician
    • 5 essential tips to help men prevent prostate cancer

      Kevin Jones, MD | Conditions
    • Unlock the power of physician compensation data in contract negotiations [PODCAST]

      The Podcast by KevinMD | Podcast
    • From pennies to attending salaries: Why physicians should teach their kids financial literacy

      Michele Cho-Dorado, MD | Finance

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...