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My understanding is that there is no “optimum” time for maintenance. The high rate of relapse after stopping buprenorphine is a sobering factor and the consequences of relapse can be severe/deadly.  Having said that, it is a reasonable goal with perhaps early on, more focus on the journey then the goal. By journey,  I mean a steady focus on establishing a robust, steady, solid, dependable, tried & true, storm proof recovery program is a must. The approach is of course individualized and there may be exceptions but they are rare in my experience.  Many people want to get off fast after feeling “normal” for the first time in years. That may be related to circumstances, flight into health or perhaps more often, shame. I try to use an MI approach in managing this. I hear the patient’s perspective and reflect it, and then (if appropriate), with permission, offer a concern about the risk of relapse.  Hope this helps.

Mike Newberry, MD

That is the $100,000 question!

The data from R-B suggested that less than 10% of the patients can be weaned off at the same time that they stayed sober. There was recent "small group discussion" where the Physician had been able to wean off 80%.

In my limited experience, less than 1% are able to wean off and remain sober.

Pedro Ballester, M.D.

There was a great webinar yesterday by Drs. Fiellin and Renner, discussing this very issue. 

http://pcss-o.org/wp-content/uploads/2015/09/FiellinRenner-Live-Webinar-9.15.15-FINAL.pdf

This presentation detailed the argument for a long-term maintenance (without the specified duration upfront) for most cases. However for patients with high motivation to stop medication but engaged in other treatment and recovery-oriented  activities and with positive prognostic factors a taper can be attempted. Seems that longer tapers are more likely to be successful and there is a possibility that some patients may benefit from a period of naltrexone maintenance post buprenorphine detoxification to minimize the risk of relapse, which usually occurs early post-detoxification. However, there is no clear empirical evidence to support these approaches only the accumulated clinical experience.

Adam Bisaga M.D.

Yes I was on yesterday’s webinar and use the strategies for taper. But my question is how long to keep a person on bup before the taper?

Elizabeth Lottes

At Minneapolis VA we are just now  looking at the data on outcomes of 299 patients treated with bupe/nx since inception in spring 2004 to spring 2015 (11 years). About 120 remain in various stages of active treatment with med while the rest are off med. From our clinical experience a year of MAT is certainly not too long and most were on MAT well beyond that. Hope to have the preliminary report at AAAP in December and a more extended report at ASAM in April.

The excellent Webinar presented by Fiellin and Renner on Tuesday was most helpful in noting the lack of substantial outcomes data.

Stay tuned.

Scott McNairy MD

Great topic, a question I ask myself (and other people) all the time.

Any published guideline references on this topic would be appreciated!

Sincerely,

Frederick Michael Elliott, MD

http://www.psychiatry.org/psychiatrists/practice/professional-interests/addiction-psychiatry/pcss-mat-archive

Click on PCSS-MAT Archive. I did a webinar on March 10, 2015 reviewing the evidence on maintenance vs. taper with both methadone and buprenorphine. The evidence for indefinite maintenance is overwhelming.

On April 14, Drs. Timothy Wong, John Renner, and myself, discussed clinical cases involving tapering, in another webinar.

These 2 webinars tie in nicely with Drs. Fiellin and Renner’s webinar yesterday.

Edwin A. Salsitz, M.D., FASAM

As it was noted, we have minimal data to determine what is the optimal duration of buprenorphine treatment to maximize long-term outcome (I presume this is most often “full recovery" - remission of symptoms+changed life). We only have observational and clinical anecdotes to guide us in this regard, and there is no controlled studies on the horizon. So every clinician develops their own approach (algorithm) to guide them. 

Here is mine:

- For patients with a history of pain I tend to recommend long-term (no pre-defined length) maintenance while trying gradually to decrease dose to 2-4 mg and keep it there. Those patients like to be on some kind of "pain-management” regimen and tend to stay on.

 -For patients with a primary addiction problem you may recommend the same approach but many  will get “tired of it” and will stop buprenorphine on their own anyway, without your help. There is some evidence that is the default mode of buprenorphine maintenance, multiple short episodes of treatment - but this is not the optimal outcome as there are additional risks involved in relapse.  

So avoiding the issue of "wanting to be off meds" is probably not very good for the patient, better to partner with them in setting the goal of controlled discontinuation early on.  Once they meet their treatment targets I recommend discontinuation attempt with  transition onto Vivitrol. They may realize along the way that they prefer to stay on the buprenorphine for longer, so at least they get a better sense of what works for them.

People who do not do well on buprenorphine (continue using despite increase in dose and treatment intensity) I recommend methadone or detoxification and transition onto Vivitrol. Some of them will do well on Vivitrol some will not, but I have not seen many who suddenly get better on buprenorphine  after failing it initially. Actually probably you will see if someone will respond to buprenorphine in the first month of treatment and it may make sense to switch treatment plan early on.

I would be interested to learn what strategies others have adopted.

Adam Bisaga

Is there data on efficacy of prolonged antagonist use?

Paul C. Coelho, MD

The longest is 18 months, a 12 month extension to the pivotal 6 months trial http://www.ncbi.nlm.nih.gov/pubmed/23701526

Conclusion: During a 1-year open-label extension phase of injectable XR-NTX for the prevention of relapse in opioid dependence, 62.3% of patients completed the phase and 50.9% were abstinent from opioids. No new safety concerns were evident.

Adam Bisaga

This is basically what I do and people who have been on buprenorphine a long time seem to do better switching over to Vivitrol. Not sure if no more daily dosing removes a trigger or if Naltrexone is just a better medicine. Currently we are involved in NIDA-CTN 0051 which is evaluating Suboxone vs Vivitrol . Trial is still going but participants are only on either medication for 6 months. I like your thought process for pain patients being on 2-4mg.

Elizabeth Lottes

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From research on MAT with methadone it seems clear the indefinite maintenance treatment for OUD has the best outcomes.  Buprenorphine was developed with same philosophy but now it seems other factors (financial and political) are attempting to sway providers into an arbitrary cut off. I agree with those above who support individualizing length of treatment based on severity of disease and degree of recovery.  The problem with this goal is the lack of standardized measures of disease severity or degree of recovery.  We don't have a HbA1C measure not do we have a validated risk assessment tool to guide a patient/provider choice.  I try to look at evidence based variables such as family history, adverse childhood events, comorbid mental health issues and current psychosocial stressors to help guide a motivational interviewing session.  Based on that evaluation I use a cancer metaphor telling those with severe addiction that they deserve the most comprehensive treatment and ongoing monitoring/disease surveillance (which is the best counseling, mutual help 12 step, drug screening available).  For those with milder disease simple buprenorphine detoxification is worth considering.  The problem, of course is getting accurate information to do the risk assessment since folks with addiction often have limited insight into the severity of their illness due to compromised frontal lobe functioning.

 

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