I recently had the opportunity to interview Mark L. Kraus, M.D., FASAM*, an addiction medicine specialist and a diplomat of the American Board of Addiction Medicine. He is also an internist in private practice and Assistant Clinical Professor of Medicine at Yale University School of Medicine.
There were two parts to the interview. In the first part, we discussed the signs of addiction and the difference between physiological dependence and addiction. You can read that portion of the interview here: Dr. Mark Kraus Discusses Opioids and Addiction
In the second part of the interview, we discussed treatment options for opioid addiction or dependence other than rehab facilities. One resource Dr. Kraus directs people to is the Web site TurnToHelp.com, which offers patient case studies, a questionnaire to determine if you might be dependent on a prescription painkiller and a physician finder to locate a doctor certified to prescribe treatment.
Suboxone as a Treatment Option
The TurnToHelp.com Web site talks about Suboxone (buprenorphine) as a treatment option for patients who have addiction problems or who want to break their physiological dependence on opioids. I noted that Suboxone is still an opioid and asked why taking it is better or safer that taking other opioids.
Dr. Kraus said, “The answer is it's a partial mu agonist. It's not exactly an opioid. It looks and smells and tastes like it, but is not exactly the same. It works at the same site in the brain, has a stronger affinity for those sites in the brain, and breaks away from them slower. So it is an opioid in that regard.
“It's an opioid that can be used very safely as was shown in a study that was conducted by the National Institute of Drug Abuse and was published in the Archives of General Psychiatry that showed that medicine-assisted treatment with Suboxone works very effectively in an office-based setting.
“The other medication we haven't mention in medical-assisted treatment for opioid dependence is methadone, which also works very well in methadone treatment programs, which are usually methadone clinics. We also know that methadone and buprenorphine can be treatments for pain and they are effective treatments for pain.
“So the point is that it (Suboxone) is an opioid and has all the properties and qualities of an opioid. It can become addictive and one needs to taper oneself off. That's not different than a pain medication patient who gets treated with an opioid. They can't just stop the opioid. They have to taper down and off. The reason is, they've established this physiological dependence, which has affected the brain chemistry. The scale is evenly weighted as to use and non-use when you want to get off, so they are similar.”
Suboxone vs. Methadone
Next I asked how Suboxone differs from methadone and whether it is a better treatment option.
Dr. Kraus said that thus far, no studies have been done to determine which patients would do better with Suboxone and which would do better with methadone. He explained that the difference is more a matter of how much structure a particular patient needs. Methadone treatment usually takes place in the more structured environment of a methadone clinic, while treatment with Suboxone is done through the doctor's office.
In some cases, a patient may start out with methadone, but as treatment progresses and they don't need as much structure, they can be transferred to Suboxone. The opposite is true as well. A patient may start out on Suboxone, but be switched to methadone if they are having problems and need a more structured treatment program. There are ways to do that pharmacology.
Dr. Kraus concluded, “I think that having the ability to be treated in one's own doctor's office is definitely good. I think that having methadone treatment programs available in communities is very important also.”
Suboxone as a Pain Reliever
Since our primary concern is pain relief, I asked how well Suboxone works as a pain reliever.
Dr. Kraus said I was out of his area of expertise but from what he has read, it is as efficacious as other opioids in treating pain.
Still on the subject of pain, I asked if Suboxone is a good option for people who have a history of addiction problems that are now dealing with a chronic pain problem but are concerned about falling back into addiction.
“I think that again it goes back to that relationship with their doctor as to what is the best thing they need to maintain good pain management,” said Dr. Kraus. “Unfortunately, there is that stigma that's attached to the addict, less so to the pain medication person – I think that has a role in it as well. Whatever works best is what should be used.
“The Drug Addiction Treatment Act of 2000 says legally you can't use Suboxone for pain, which is kind of schizophrenic because there are things out there for pain with buprenorphine like Butrans (patches). In the world out there, from the policy makers, there's a little bit of schizophrenia as to whether you can use it or not. That's hard.”
Dr. Kraus went on to again stress that the relationship between the patient and doctor is special and together they need to work out what treatment is best.
Starting Suboxone Treatment
Because one of the ways Suboxone works is by blocking other opioids from getting to the mu opioid receptors, I asked if one has to be completely off of other opioids before starting Suboxone.
Dr. Kraus answered, “If they're going to a certified, wavered physician for treatment with Suboxone for their opioid dependence, then in order for it to work really well, they have to come off completely from their other opioid. They have to stop and they have to be in withdrawal because you're trying to do is to have the Suboxone lock on to those receptor sites and own those receptor sites. What you're really doing is gaining control. Now if the other opioids are there, they can get kicked off. If you induct someone with Suboxone who is still taking opioids, they can actually be tossed into withdrawal. That's something that you don't want to do.
“When we induct a patient who is opioid dependent, that meets the criteria, then what we're going to do is we're going to tell them to stop the opioid. If it's a long-acting opioid, it may be for three to five days; for a short-acting opioid it might just be 14-18 hours. They go off of that and then you induct them with Suboxone. The induction would be relatively easy, smooth and not cause any effects like withdrawal.”
Suboxone, Surgery and Emergencies
Because Suboxone blocks other opioids from the receptors, I've always wondered what happens to patients who need surgery or have a serious injury and need stronger pain relief than Suboxone provides.
Dr. Kraus explained, “We actually have protocols for that. In fact, there's a Web site called The Physician's Clinical Support System. Doctors can join that and they can get information on just how to handle what you've brought up.”
“For elective surgery, you stop their Suboxone the day before. They go to surgery. When they wake up, you treat them with pain medications. They can be treated immediately so they feel ok and they can recover. When their pain is markedly reduced from the surgery they had, you stop the opioid they were given for pain and then re-induct them under Suboxone.
“For someone who has a fracture or slips, falls and breaks a hip, or someone who has a dental procedure, or someone who has an acute appendix, what you would do is stop the Suboxone from the moment they went to the emergency room, went to the OR, or went to get their fracture fixed. Then the next day you would start them on opioids. And again, treat them with opioids until which time the doctor feels we can switch them back; then stop the opioid and re-induct them on the Suboxone.”
As we finished our conversation, I asked Dr. Kraus if there was anything else he would like to share with our chronic pain community members.
He answered, “The thing I'd like to leave you with is that there is treatment available for opioid dependence. It works. We have medical-assisted treatment in an office-based setting, medical assistance with Suboxone, and medical-assisted treatment in a methadone clinic. They work. They help people get better. There are trained addiction specialists and medicine and psychiatrists. There's even a board now, the American Board of Addiction Medicine, that's joined the family of medicine.
“There is an overlap between pain and addiction, which is what we talked a lot about. I think that addiction specialists – I know I do in my community as an addiction specialist – work very closely with my pain specialist colleagues. We get in cases where we really need to team it to make it go. There's that kind of professionalism and availability in most communities.”
I thank Dr. Kraus for sharing his time and expertise with us.
More Information on Suboxone
As I mentioned earlier, you can get more information about Suboxone at the TurnToHelp.com Web site.
Our own ChronicPainConnection expert Dr. Christina Lasich is certified to prescribe Suboxone and has written two articles about it:
Suboxone: An Exit Strategy
Suboxone: Here to Help Program
* MORE ABOUT MARK L. KRAUS, MD:
Mark L. Kraus, M.D., FASAM is a General Internist in private practice at Westside Medical Group, Waterbury, CT. Dr. Kraus is a fellow of the American Society of Addiction Medicine (ASAM) and a Diplomat of the American Board of Addiction Medicine. Dr. Kraus is an Assistant Clinical Professor of Medicine at Yale University School of Medicine. He does clinical research in the field of Addiction Medicine, and teaches Addiction Medicine and General Internal Medicine to the Yale General Internal Medicine Residents. Dr. Kraus has written numerous articles and chapters on the subject of Addiction Medicine, and has lectured internationally, nationally and locally in the field of Addiction Medicine.
Published On: November 30, 2011