An individual calls inquiring about the program and is informed whether we are accepting new patients. If we are unable to accept new patients we refer people to programs in the area that have short or non-existent waiting lists and encourage them to call back regularly and ask about upcoming orientations with us if that is their preference.
If we are accepting new patients, we inform individuals of our next scheduled “Program Orientation” and invite them to register. We do not keep a waiting list because we have discovered it is difficult to contact people whose lives are chaotic.
We schedule a group meeting for potential applicants to inform them of our core beliefs and treatment expectations. We distribute and read aloud item by item our treatment contract and everyone leaves with a sample copy. No one is signed up at orientation and we ask people to seriously consider if this is the program for them. If they concur, they are asked to schedule a therapist intake in the following days. It is only after an intake with the therapist and the treatment contract is again gone over and signed, with each item initialed, that they are given an appointment with the prescribing physician. We feel this sequence helps prevent future misunderstandings by ensuring knowledge and clear understanding of expectations.
New patients are asked to arrive 20 minutes before the session to complete paperwork and sign necessary releases of medical information from other providers and institutions. The first questions asked are: “How did you feel about the orientation? What are your concerns? Can you imagine succeeding in this program? Where do you see yourself regarding willingness to change?” We always ask: “What is the lowest dose of Suboxone you can function at?”
Almost 100% of our patient population has been taking Suboxone on the street and are familiar with personal dosing. It is not uncommon for some individuals to share honestly: “I can be fine on 4 mg a day.” or “I can get by on 4 mg but I would rather have 8.” This important information is recorded and shared so the medical provider will be prepared to engage in an honest discussion at their first appointment.
The history is taken with a special emphasis on an individual’s substance abuse history and is standardized with the hope of creating an area-wide data base set from which outcome research can grow. We are most interested in understanding previous experiences with treatment and what has “worked” or “not worked” in the past. We are aware that many individuals enter treatment for substance abuse multiple times and may succeed after multiple attempts. Program members are reminded that there is a mandatory initial 10 week “Skill Building Group” and 10 Week Individual counseling requirement followed by the assignment to a long term, weekly “home” recovery group.
Every new program member is given a copy of the signed treatment contract as well as the specific information regarding the start date of the Skill Building Group (usually an evening group, 5:00-6:30pm) and the phone number of the individual substance abuse-trained counselor (preferably LCSW/LADC) who is in partnership or on staff with the program. This counselor will be providing the individual counseling for 10 weeks at a minimum and be in close communication with (or a member of) program staff.
We STRONGLY encourage program members to remain in individual counseling and stress the importance of healing from the “inside out” to truly recover from addiction. Many program members have high (above 4) ACE (Adverse Childhood Event) scores. We speak directly about the need to address trauma and the improved outcome with comprehensive treatment. If a person is already in counseling, we ask to be able to speak to their therapist to share our program model and assess if our concerns can be incorporated in their work together. We also support involvement in 12 step groups. We cannot require attendance in 12 step groups but speak often of the benefit of developing ongoing, relationships with others in recovery following the 12 step model.
After the intake interview, signed releases and treatment contract review, a new program member is scheduled to see the provider. The provider assures completion of all items on the “Induction checklist”, adjusts the medication dose, and begins to engage in honest dialogue with the patient.
This is an important appointment for new program members who are anxious and hopeful about their medication needs and personal recovery goals.
The provider is also the co-group therapist in the 90 minute weekly recovery groups. The new member is placed on a schedule of weekly prescriptions to offer the support and accountability that new recovery requires. These individual provider/patient visits are gradually lengthened as the need requires, to a maximum of once monthly. Our model puts the doctor/patient relationship of first priority in the process of healing from addiction. The provider taking the time to sit in on the group process is highly valued by our program physicians and members and referenced repeatedly in comments. “This is the first time in my life I feel my doctor really knows and cares about me personally.”
The mechanics of induction are not difficult. If a patient has been on another opioid in the days before, the provider asks when and what, and lets the patient know that if they take buprenorphine too soon after using another opioid (ie, if not yet in mild withdrawal), then they can withdraw suddenly, and so it is in their best interest to be honest. This begins the sharing of responsibility in the process of recovery. Most patients are familiar with buprenorphine or are already taking it and know “their dose,” the dose at which they feel comfortable. Methadone is a particular case that needs more special attention because it is lipophilic and has a long and variable half-life. A 48-72 hour wait is generally required after the last dose in order to prevent abrupt withdrawal. If there are any question a formal COWS (Clinical Opiate Withdrawal Scale) can be performed and it is best to wait until a patient is in moderate withdrawal (score >12).
The difficult part of induction is that it needs to be a dialogue, two people meeting honestly, and unfortunately one of those persons has been engaged in vigorous deception in order to get his or her immediate needs met over the past months or years. On entry, patients usually will say they need the highest dose they think they can obtain; this is expected addictive behavior. It is wise for the provider to have a maximum dose clearly in mind (perhaps from previous discussions between the patient and the therapist who, as a non-prescriber, has elicited a more honest answer). Choose wisely and stick by it, being willing to help people find another program if they feel they can’t start at such a low dose.
We use 6mg as our maximum dose for all non-pregnant patients, and we have yet to have a patient refuse because the dose is too low, although we have started at higher doses for those who we feel are committed to recovery but are likely to relapse at this dose. We feel a low starting buprenorphine dose (a) decreases community diversion, (b) self-selects for motivated people to enter the program, and (c) discourages those who are less serious about their recovery.
Pregnant women are an exception because the fetus is also being treated and withdrawal risks have more serious consequences. We generally provide whatever the patient requests within reason, given their recent drug history.
Suboxone is rapidly absorbed sublingually and if the dose is uncertain a patient can start with one 2mg film, adding 2mg every two hours, up to your program’s maximum daily dose (most will end up needing the maximum dose). They can sit in the waiting room for the day, or can be seen a day or two following, prescribing enough medication for the interim.
Alternatively, the lowest tolerated dose can be negotiated with encouragement to try it for a week, maintaining availability if more is needed in the interim. It is important that with the initial dose the patient feel stable, because stability in the coming weeks and months is key to recovery.
During the first 10-week skill building phase, a program member is attending weekly individual counseling, seeing the provider on a weekly or biweekly basis for refills, and attending a weekly, 90 minute Skill Building Group session (maximum 12 members). The Skill Building sessions contain more didactic material than subsequent home group sessions, but with plenty of input from participants. Subjects include:
- Exploring values
- Defusing from the addiction
- Exploring and setting goals.
- Value based avoidance
- Building recovery skills, part 1
- Building recovery skills, part 2
- Quality of life: Value based living
When patients first enter the recovery program they are like deer in a car headlights. They are confused, desperate, grasping for help, and in dire need of assistance. As they stabilize on their initial dose of buprenorphine, people often enter a honeymoon period lasting a few weeks, in which they feel tremendous relief that they no longer need to search for their next hit. They will be grateful, compliant, and happy.
Beware if they want to stop and rest here. Many will be homeless, penniless and jobless, and all will have left a wreckage of traumatized families and destroyed relationships in the wake of their addiction. There is much work to be done.
Beware, too, if they want to fix everything at once. Mending social and life problems cannot be done overnight. People will need help prioritizing, taking a sequence of small steps rather than one huge one. Maslow’s hierarchy of needs will come in handy. Housing, employment and safety come first. Then repairing relationships. People quickly learn that it is best to lose all one’s old friends for a time, change cell phone numbers, erase old dealer’s names and numbers, and stop going to old haunts which contain the triggers to use. There will be issues and dilemmas along the way. As the drama lessens, amends will be made, regrets expressed, bonds reforged.
After completing 10 weeks of the Skill Building phase, a program member is assigned to her/his ongoing, weekly 90 minute home group. Prior to this transition a member will be given our "Rules of Being in Group." Hopefully this group will become an important source of support, feedback and instruction while creating a sober, value-based, stable life. Most program members remain in the same group during their entire time in the program. We have noted that when groups are cancelled because of weather, holidays, or provider vacation time, members report an uptick in relapses.
Step 6 can continue for a long time if a group member is doing well, not using illicit drugs, not using marijuana, and developing a value-based life. Tapering is occurring at a rate the individual feels ready for. Several individuals have been in the program for over four years, and as long as one is making steady progress in one’s life goals, we do not insist on tapering but rather see it as one of many priorities to a better life. It can, alternatively, be a simple, straightforward goal that anyone can feel proud of achieving.
Some caveats from the provider’s point of view during this time of stabilization:
- Due to chaos and social turmoil, people often overlook deadlines, forget appointments, cancel their cell phone service — but they almost never miss their buprenorphine refill appointments. This can be useful. For example, getting refills after group meetings or other obligations assures attendance. If a patient repeatedly arrives tardy to group, providing refills before group meetings can help. If patients keep asking for early refills, shortening the interval of refills and seeing people more frequently will help.
- See the work as essentially collaborative. See the patient as driving the car of his/her recovery, the provider and therapist as “backseat drivers,” or perhaps the “good” trusting parents they never had, giving advice.
- Don’t forget that you own the car, that you are the parent, and that you control the Suboxone; negotiate reasonable expectations and hold patients accountable to what is visible and measurable.
- Your best tool is your relationship with the patient, and it matters. It has been said that if “relapse” is a drifting away, then “recovery” is reconnecting. They will shine with your praise and wither with your criticism. Use both carefully.
- People who abuse drugs are generally more clever than the provider and more knowledgeable about drugs; the provider needs to accept that he or she will be fooled some of the time. If a patient says he or she “needs” a higher dose, inquire nonjudgmentally about the need. Usually the reason involves anxiety, pain, insomnia, or some other issue that the patient can learn to address in non-drug ways.
- Emphasize the positive. Most lack self esteem and are full of shame and regret. Compliment any small progress.
Watch for and address signs of impending relapse such as early refills, missed group meetings, or continuing social chaos.
An Approach to Tapering
Most people in recovery eventually want to taper off buprenorphine. It is usually toward the bottom of their list of “to-do” life issues, so it comes months or perhaps even years after stabilizing in a recovery program. It generally remains higher on the provider’s to-do list than the patient’s. But it usually is on both of their agendas, a shared goal.
It should be emphasized that the desire to taper comes from the patient, not from the provider. For both patient and provider, real recovery involves other life changes first, and tapering happens only if patients have made gains in other areas of their life first: ridding oneself of user friends, maintaining stable relationships at work and at home; getting promoted; getting educated. And then, at some point most patients one day walk into the room and state that they are ready to taper.
They do not want to experience withdrawal symptoms, so the slower the tapering the better, and they want to feel they are in control of the process. Sobriety most of all requires a willingness and desire to change, which comes from within, after felt gains from previous changes. Change is not comfortable or pleasant, but it can lead to huge personal rewards. If it is coming from the patient, the motivation to continue, the felt progress, builds.
As the dose gets lower (toward or under 2mg per day of buprenorphine), the harder part of tapering becomes the mental part, the loosening of old habits and rituals, the fear of the unknown, the anxiety of being without their stable and always ready “friend.” There is no truth to the idea that “the longer you take it, the harder it is to stop,” except that old habits die hard. Detours often occur; patients will stabilize at a certain dose for months before resuming a taper. The goal is to stay in the game, hour after hour (after hour). Moral support and wisdom help. Slow and steady is the rule. If stress or drama intervenes it is often best to interrupt tapering and keep the dose steady until life issues are resolved.
Below are some positive indicators that a patient may be getting ready to taper, when it can help to ask in a nonjudgmental way if they can imagine or have ever thought of coming down on their dose. The more of these items are present, the better the chance of success:
- Taking buprenorphine regularly, once or at most twice per day, and not in response to depression, fatigue, emptiness, insomnia, or urge.
- Having month after month with no extra calls reporting lost or stolen buprenorphine, no “very bad weeks” where everything went wrong and forcing the need to “take a little extra.”
- No use of intoxicants (alcohol, marijuana) and no issues with ongoing depression or anxiety needing medication—i.e. the ability to ‘live life on life’s terms.’
- Stable job, stable finances, stable relationships, and preferably one or two hobbies or ‘passions.’
- Complete loss of user contacts, and no immediate access to opioids (no spouse on pain or anxiety pills, no dealer calling every few days, etc).
- No chronic pain, or acceptance that one will have to tolerate one’s pain.
- Being on a regular exercise schedule.
- Fear of relapse.
- Age over 30. Age brings wisdom, persistence of intent, insight into emotions, and the realization that life is temporary and precious.
The best strategy in starting to taper is to move slowly, stay stable, avoid drama. At higher daily doses (16mg down to 2mg), buprenorphine’s long half-life can be taken advantage of, since physical withdrawal symptoms will not begin until more than 48 hours after the last dose. For example, lowering a single day’s dose by 2mg one day per week, though possibly anxiety-provoking, will hardly be noticed physically. If a patient is taking 8mg daily and says she wants to taper but is worried, suggest she try to take 6mg one day in the next day or two, 8mg the other days, and report back a week later with 2mg left over to see how it went, remaining (except for that one day) on her 8mg dose. Uniformly, patients are pleasantly surprised by how easy that was. Then, rewarded, patients can progress by dropping another 2mg on widely separated days, with no untoward effects, reinforced by the progress they are making.
Below buprenorphine’s “ceiling dose” of about 2mg per day, its half-life will be shorter, and for most people this will bring on withdrawal symptoms sooner. Taking the same dose but split into several doses a day is one strategy that often works (avoid taking it more than four times a day because dosing itself can become a fixation). Films can be cut with a razor blade or hobby-knife down to very small doses. Printable cutting guides are available on the internet. Cut two mg strips into 0.25, 0.12, 0.06, 0.03 and 0.015mg squares and put them in separate baggies.
Everyone is different, but here are some guidelines:
- Above 16mg: decrease daily dose by 2-4 mg per month
- 16 to 8mg: decrease daily dose by 2mg per month (= 4 months)
- 8 to 2mg: decrease daily dose by 1mg per month (= 6 months)
- 2 to 1mg: decrease daily dose by 0.5mg per month (= 2 months)
Below 1-2mg the approach needs to be individualized. Some people prefer to hang out at 1mg or 2mg for months or even years before they feel ready to “jump off.”
The lower the dose below 2mg, the easier it is to jump, but the harder it is to maintain that low dose while getting ready to jump, because of the unsaturated receptor sites. Everyone is different, but usually, somewhere between 1mg and 0.25mg per day, people who are motivated to get off the drug and who feel their life is stable and supported, can successfully decide to stop.
Withdrawal symptoms usually peak around 48 to 72 hours after the last dose. This will be the hardest time, but it does not get rapidly better after that. If possible, people should plan for 10 to 14 days off work and other stressful activities, or some support person present for this time and a way to stay busy – whatever seems right to the patient. Work or school can help keep one’s mind off the craving but it is important to anticipate the strong negative feelings that will occur while jumping off. People feel unmotivated and exhausted after a few hours of work, easily overwhelmed and even depressed, for a month or more, as they adjust to their new sobriety.
Most people begin to emerge into a new sober life as the weeks progress. Sleep will slowly get better, mood will rise, and they will begin to feel again the full power of their feelings — happiness and discontent. This is when having other reasons to keep going, other pursuits, endeavors, passions to give one’s life meaning, becomes most important.
What patients can do:
- It is difficult if not impossible to quit on one’s own, and it helps to feel there is a “support team,” so coordinate the plan with all concerned. The provider should be on the team, and notify one or two reliable friends or family members to be on “standby.”
- Avoid caffeine. Moderation is always a good rule, so limit caffeine intake to maybe 2 drinks or cups per day, and those before 3pm.
- Eat regularly and consume a healthy diet. Your body is having a hard time now, and needs you to feed it good healthy food! Vitamins C and B6 supplements might also help.
- Exercise every day. Exercise works as an antidepressant, helps you feel good about yourself, and is good for you. Maybe all of those things are the same, (or maybe they aren’t), but exercise works.
What providers can do:
Being available, being perceived as “part of the support team,” is most important. This is a joint effort, and you are a trusted colleague. In addition, there are specific medications that can help specific symptoms:
1 tablet three times daily for three days, then 1 tablet twice daily for three days, then 1 tablet once daily for three days, then stop
**Dispense in 3-day supplies, hold if BP < 90/60**
1 to 2 capsules every 4 to 6 hours as needed (max 6 doses/day)
1 tablet every 4 to 6 hours as needed (max 4 doses/day)
1 capsule every 4 to 6 hours as needed (max 6 doses/day)
2 tablets first dose, then 1 tablet after every loose stool (max 8 tabs/day)
2 tablets every 30 to 60 minutes as needed (max 8 doses/day)
½ (one-half) tablet every 8 hours as needed (max 3 doses/day)
1 tablet every 8 hours as needed (max 3 doses/day)
2 tablets every 4 to 6 hours as needed (max 4 doses/day)
1 tablet every 4 to 6 hours as needed (max 6 doses/day)