Buprenorphine used to shape behavior for those in recovery

From the Winter 2017 edition of Vanderbilt Medicine Magazine

Charles* is one of the lucky ones.

Three decades after he first sneaked his little brother’s hydrocodone cough medicine, 20 years after he started dissolving morphine pills in a heated spoon and injecting the milky solution into his veins, Charles has found his way back to what he calls a “normal” life.

He didn’t die from an overdose or liver failure. He didn’t end up in prison, and he didn’t commit suicide. Call it chance, fate or divine intervention, in 2004 Charles became the first patient enrolled in a new “medication-assisted” treatment program at Vanderbilt Psychiatric Hospital, part of Vanderbilt University Medical Center (VUMC).

The drug he takes, buprenorphine, works like methadone. It blunts his craving for hydrocodone and morphine without causing an opioid “high.” He can only get the drug if he participates in a recovery program that includes individual and 12-step facilitated group therapy.

“It’s been amazing,” says Charles, now 47, who requested anonymity because his co-workers don’t know his history. “I’ve been able to work, buy a house.” Even so, he says, “it’s a daily struggle. I’ve slipped up, relapsed even on the buprenorphine. But (the program) outweighs anything I’ve been through before.”

Buprenorphine, a long-acting opiate developed in the 1970s as a “safer” analgesic, has become a mainstay of many drug treatment programs. Although less addictive than its sister drugs, hydrocodone and Demerol, it still has potential for abuse and has earned in some circles the nickname “prison heroin.”

“There are people who abuse it,” says Reid Finlayson, M.D., associate professor of Clinical Psychiatry and Behavioral Sciences. “And people have died from overdosing on buprenorphine.” But when it’s given as part of a treatment program, it helps addicts “stabilize” so they can work on their recovery, he says.

About a decade ago, Vanderbilt Psychiatric Hospital’s drug treatment program became the first in the region to use buprenorphine to treat opioid dependency. At about the same time, Peter Martin, M.D., was participating in a national trial testing buprenorphine in opioid-dependent pregnant women.

Published in 2010 in the New England Journal of Medicine the Maternal Opioid Treatment Human Experimental Research (MOTHER) study found that infants born with opioid dependency who received buprenorphine required shorter periods of treatment for neonatal abstinence syndrome (NAS) and shorter hospital stays than those treated with methadone.

“At that time the standard of care for the treatment of opioid-dependent women was methadone,” says Martin, professor of Psychiatry and Behavioral Sciences and founder of the Division of Addiction Psychiatry. “Our paper changed that.”

Buprenorphine doesn’t prevent NAS, says Stephen Patrick, M.D., MPH, M.Sc., assistant professor of Pediatrics, but getting pregnant women off prescription opiates or heroin will decrease their risk of dying from an overdose and increase the chances that their babies will go to term and have higher birth weights.

“As a neonatologist, that’s an OK trade-off,” Patrick says. “I’d rather see healthy moms and fewer babies born preterm.”

Martin did a similar calculation when, in 2004, he admitted Charles to the buprenorphine recovery program at Vanderbilt Psychiatric Hospital. Charles, he says, “was so addicted to opioids that he would go to dentists to have teeth pulled.”

“Just about all of my teeth were pulled, perfectly healthy teeth. You’d just say it hurts. A dentist in town was ready to help. He’d give me Percocet,” Charles says.

A mouth has only so many teeth. So Charles started hanging out at drug stores. He’d approach elderly people as they left with their little white prescription bags. Some of them needed money more than they needed their medicine.

After a few years, Charles turned to morphine. He’d dissolve the pills in a heated spoon and inject the solution into a vein in his arm. Then his veins started to collapse. Not only was he physically ill, he was just plain tired.

Increasingly, he thought about suicide.

“The closest I got was in 2004,” he says. “I put some bleach in a syringe. I was ready to be done with it. I thought about it for several hours, and decided I don’t want anyone to find me like that.”

That’s when Charles came to Vanderbilt. But he found more than buprenorphine. He discovered that what he’d always considered to be a moral failing was nothing of the kind. He had a chronic disease that he would have to learn to manage—for the rest of his life.

“Buprenorphine is used to shape behavior,” explains Martin, co-author of the book, “Healing Addiction.” Only if patients consistently practice proper behaviors for recovery will they get the medicine. “Ultimately, patients have to be able to do this on their own,” he says.

“Vanderbilt was the first place where I was taught that addiction is a disease,” Charles says. “Dr. Martin was the first doctor to get me to understand that it has to be treated every day. You have to work on what got you started in the beginning.”

* Charles’ last name has been omitted to protect his privacy.