Long-term Suboxone Maintenance Therapy for Opioid Use Disorder: 2 Case Reports

The medical profession is divided in its approach to treating patients with addiction issues, particularly in regards to the treatment of opioid use disorder with Suboxone (buprenorphine/nalo-xone). Here we present two cases of patients who have achieved over 11 years of sobriety with long-term Suboxone maintenance therapy. Their stories help to demonstrate that Suboxone is a viable long-term treatment option for severe opioid addiction. While lifelong Suboxone use can lead to physical dependence on the drug, this is far from simply replacing one addiction with another. Some providers may feel that physical dependence on a medication does not represent appropriate or adequate treatment of opioid use disorder; however, when compared with the grave potential consequences of severe opioid use disorder, the potential benefits of achieving sobriety with Suboxone maintenance far outweigh the risks.


Introduction
It is well known that some organizations as well as individuals within the medical field have a negative opinion regarding long-term pharmacological management of addiction.In particular, there is uncertainty regarding the treatment of opioid addiction with Suboxone (buprenorphine and naloxone).Despite the fact that Suboxone has been FDA approved and indicated for opioid maintenance therapy since 2003, some physicians remain reluctant to prescribe the medication.Much of this uncertainty may stem from the belief that in initiating long-term Suboxone maintenance, one merely replaces one addiction with another.This common misconception can create a significant barrier to adequate provision of care for patients suffering from opioid addiction.Here we present two cases of patients on long-term Suboxone maintenance therapy who have achieved sobriety for periods in excess of 11 years.

Cases
Patient JM is a 67-year-old male who presented for treatment of opioid use disorder in August of 2003.JM's substance use history also includes tobacco, alcohol, marijuana, cocaine, LSD, and psilocybin ("magic mushrooms").JM's first exposure to opioids occurred at the age of 16.He reported that he used opioids only occasionally at first because they were difficult to obtain; however, he began to significantly increase his use his in his 40s when he discovered he could obtain large amounts of Vicodin via the Internet.JM reported taking Vicodin daily for a period of 15 years.He began taking the medication in increasing doses until he was taking 14 or more 10 mg tablets per day.JM reported heavy alcohol use during this time as well.
JM's drug use began causing significant social, occupational, emotional, and financial difficulties.In an attempt to curb his alcohol and opioid use, JM began attending Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings.He also attended drug rehabilitation programs on 4 separate occasions and was seen by an addiction medicine specialist.Despite these interventions, JM reported that his longest period of sobriety was only 3 months.
In addition to the expenses incurred from purchasing opioids, JM's also went through an emotionally painful divorce.He was terminated from his job on three separate occasions as a result of his continued drug use.While JM eventually remarried, his addiction continued to create problems in his new marriage.Furthermore, JM noted that his opioid use prevented him from building strong relationships with his young children.
After a lengthy discussion with his wife, JM agreed that he would make one more attempt at achieving sobriety.He enlisted the help of a new addiction medicine specialist, Dr. Mohammad, who developed a treatment plan with him.JM was detoxified in an outpatient setting and was started on daily Suboxone maintenance.Since starting Suboxone, he has abstained from all drugs, including alcohol and tobacco.His cravings have been almost completely absent and he reported improvements in all aspects of his life.His relationships with his wife, children, and friends improved significantly.He was able to maintain a steady job and take control of his finances.Currently, JM continues to take daily Suboxone maintenance.He has been sober for more than 11 years.
Patient MJ is a 54-year-old male who presented for treatment of opioid use disorder in 2003.MJ reported a significant substance use history including alcohol, marijuana, cocaine, LSD, psilocybin, and opioids.MJ reported that his substance use began affecting his relationship with his wife and children beginning in his late 20's.At this time, he had not yet had any exposure to opioids.He began attending AA and NA meetings.After 7 years of consistently attending meetings, MJ was able to stop using marijuana, cocaine, and alcohol.MJ later joined a church support group, with whom he met at least once a week.This worked well for him until he was prescribed opioids after sustaining multiple back injuries in his 40's.
MJ first began using opioids at the age of 45 to treat his severe back pain.Initially, he received prescriptions for Vicodin 10 mg #30 on a monthly basis.He would also receive occasional Demerol (meperidine) shots as well.Over time, MJ reported developing a tolerance to narcotic medications, requiring increasing doses to adequately control his pain.Around the same time MJ began using his medication more frequently and in higher doses, even when he did not have any pain because he enjoyed the way it made him feel.
Because MJ was taking more than his prescribed dose, he began obtaining additional opioids from a variety of sources.At first, MJ was able to acquire a sufficient supply of medication by "doctor shopping".He would visit 2 -3 physicians on a monthly basis, each time complaining of severe back pain requiring opioids for adequate relief.However, the physicians eventually discovered his scheme and discontinued his pain medications.Left without a reliable source of opioids, MJ quickly began searching for other means to obtain drugs.He convinced his wife to ask for prescription pain medications from her physician.He also borrowed or stole money from friends and family in order to purchase even more drugs from street dealers.His addiction continued to worsen over a period of 2 -3 years until he was taking upwards of thirty 10 mg tablets daily.
After using opioids for a few months, MJ states that he was unable to achieve a single day of sobriety.His problems with his wife and children progressed and his wife began threatening to leave him.He reported losing many of his friends due to his continued opioid use.He lost his business as well.As his opioid use began to spiral out of control, he found himself increasingly in debt.He continued to borrow and steal to keep up with his drug habit.At one point, MJ found himself unable to repay some of his debtors; as a result, he received multiple threats on his life.MJ descended into deep despair.He was hopeless that he could turn his life around.Then, he read about Dr. Mohammad in a newspaper ad and decided he would make a final attempt at achieving sobriety.He discussed the idea with his wife, who agreed to help him with his recovery.MJ was detoxified in an outpatient setting and was started on daily Suboxone maintenance.Since starting Suboxone, he has abstained from opioid use completely.He did not experience relapses with opioids or any other substances.His cravings have been almost completely absent and he reported improvements in all aspects of his life.His relationships with his wife, children, and friends were significantly improved.Although he was unable to regain control of his business, he was able to maintain a steady job and take care of his financial obligations.Currently, MJ remains on daily Suboxone maintenance.He has been sober for more than 11 years.

Discussion
Worldwide, opioid misuse and addiction is a serious problem, with an estimated 15.6 million illicit opioid users, 11 million of whom use heroin [1].Even more concerning, it is estimated that global misuse of opioids is increasing.Furthermore, while pharmaceutical opioids are legal, their misuse is becoming increasingly common.In the United States alone, it is estimated that 5.3 million people take pharmaceutical opioids for nonmedical purposes.Of these individuals, 36% meet DSM-IV criteria for opioid abuse or dependence [2].
The scope of this problem demonstrates the need for continued efforts in the field of addiction medicine.Most current treatments involve relatively short periods of pharmacological management with or without psychosocial interventions (e.g.motivational therapy or cognitive behavioral therapy) or support groups (e.g.Alcoholics Anonymous, Narcotics Anonymous).Unfortunately, despite these treatment options, relapse rates remain very high.
As physicians and scientists begin to form a better understanding of the potentially permanent changes in brain chemistry that can occur as a result of long-term addiction, there has been an increasing level of acceptance regarding the treatment of addiction as a chronic disease.As with other chronic diseases such as diabetes, hypertension, and asthma, severe cases may require lifelong medical management; however, within the medical community, there is still some resistance to long-term maintenance therapy for opioid use disorder.Some physicians are reluctant to treat their patients with Suboxone because they believe that use of this medication will simply lead to replacing one addiction with another.While it is true that some patients will remain physically dependent on Suboxone, there are important differences between physical dependence and addiction.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) [3] uses specific criteria to aid in the diagnosis of opioid dependence, including tolerance, withdrawal, as well as multiple criteria indicating loss of control over use despite adverse consequences.Although individuals who are physically dependent on a medication such as Suboxone may exhibit both tolerance and withdrawal, the key difference is that these individuals do not experience the same loss of control over use of the drug and subsequent adverse consequences [2].Both patients described in the cases above report that after beginning Suboxone maintenance, they no longer spend a significant amount of time getting, using, or recovering from use of the substance.They are able to fulfill their responsibilities at home and at work.Suboxone use does not cause problems with their relationships; rather, it allows them to rebuild and nurture them.Both patients are able to begin participating in important social, occupational, and recreational activities to a level that is impossible when they are addicted to opioids.Furthermore, because Suboxone is a legal substance, they are no longer placing themselves in dangerous situations to obtain drugs from street dealers.After initiating Suboxone maintenance, both patients report that the medication has been life-changing, allowing them to regain their independence while improving the quality of not only their own lives, but also the lives of those closest to them.
Individuals suffering from opioid use disorder face a long, difficult journey to achieve sobriety and even for those who seek help, relapse rates remain high.Although there have been very few large-scale studies on long-term Suboxone maintenance therapy for opioid use disorder, the available literature indicates that this medication has shown some promise [4]- [10].While treatment of opioid use disorder and other addictions remains a difficult task, these cases demonstrate that continued sobriety may be achieved by approaching opioid use disorder as a chronic disease requiring appropriate long-term medical management.
Opioid use disorder is a problem.There are a number of treatment options available and the current focus seems to be on brief periods of pharmacological management, with or without psychosocial interventions such as motivational therapy, cognitive behavioral therapy, or support groups (e.g.AA, NA, etc.).Unfortunately, even with our current medical arsenal, relapse rates remain high.Addiction is a chronic disease that can lead to permanent changes in brain chemistry that may necessitate a different approach in order to achieve long-term sobriety.Appropriate management of many other chronic diseases such as diabetes, asthma, or hypertension may sometimes require life-long treatment.Some doctors are apprehensive about initiating long-term maintenance therapy because they believe they are replacing one addiction with another, but this is not the case.Physical dependence is different from addiction.As these cases demonstrate, continued sobriety may be achieved by approaching opioid use disorder as a chronic disease requiring long-term medical management.