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Frequently Asked Questions

To learn more click on the topic which interests you. If you have a question which is not included, please email us and we will try to answer it.

Is buprenorphine treatment just switching one addiction for another?
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No– With successful buprenorphine treatment as part of a complete treatment plan including counseling, the patient can put the addictive behavior into remission. Buprenorphine will maintain some of the preexisting physical dependence, but that is easily managed medically and eventually resolved with a slow taper off of the buprenorphine when the patient is ready. Physical dependence, unlike addiction, is not a dangerous medical condition that requires treatment. Addiction is damaging and life-threatening, while physical dependence is an inconvenience, and is normal physiology for anyone taking large doses of opioids for an extended period of time.

It is essential to understand the definition of addiction and know how it differs from physical dependence or tolerance.

The American Academy of Pain Medicine (AAPM), American Pain Society (APS), American Society of Addiction Medicine (ASAM), and NAABT recognizes these definitions below as the current accepted definitions.

I. Addiction:
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

II. Physical Dependence:
Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

III. Tolerance:
Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.

Physical dependence and tolerance are normal physiology. Addiction is a disorder that is damaging and requires treatment.

When a patient switches from an addictive opioid to successful buprenorphine treatment, the addictive behavior often stops. In part due to buprenorphine’s long duration of action, patients do not have physical cravings prior to taking their daily dose. The drug seeking behavior ends. Patients; regain control over drug use, compulsive use ends, they are no longer using despite harm, and many patients report no cravings. Thus all of the hallmarks of addiction disappear with successful buprenorphine treatment.

Therefore, one is not trading one addiction for another addiction. They have traded a life threatening situation (addiction) for a daily inconvenience of needing to take a pill (physical dependence), as some would a vitamin. Yes the physical dependence to opioids still remains, but that is vast improvement over addiction, is not life threatening, and it can easily be managed medically..

Addiction is a brain disease that affects behavior. This addictive behavior can be devastating to the patient and their loved ones. It’s not the need to take a medication that is the problem, many people need to take a medication, but rather it is the compulsive addictive behavior to keep taking it despite doing harm to one’s self or loved ones that needs to stop. Whether or not the person takes a medication to help achieve this shouldn’t matter to anyone. If a medication helps stop the damaging addictive behavior, then that is successful treatment and not switching one addiction for another.

How to find buprenorphine treatment.

Sources:

The Essence of Drug Addiction- By Alan I. Leshner, Ph.D., Former Director, National Institute of Drug Abuse, National Institutes of Health
http://www.nida.nih.gov/Published_Articles/Essence.html
http://www.naabt.org/tl/The_Essence_of_Addiction.pdf

What’s in a Word? Addiction Versus Dependence in DSM-V - CHARLES P. O’BRIEN, M.D., PH.D. NORA VOLKOW, M.D.
http://ajp.psychiatryonline.org/cgi/reprint/163/5/764

NIDA publication: The Neurobiology of Opioid Dependence: Implications for Treatment Thomas Kosten MD, Tony George MD http://www.nida.nih.gov/PDF/Perspectives/vol1no1/03Perspectives-Neurobio.pdf

The American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine - consensus document – February 2001, http://www.painmed.org/pdf/definition.pdf
American Academy of Pain Medicine - http://www.painmed.org/
American Pain Society - http://www.ampainsoc.org/
American Society of Addiction Medicine - http://www.asam.org/

2/08



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What exactly is Buprenorphine?

Buprenorphine (BYOO-pre-NOR-feen) is an opioid medication used to treat opioid addiction in the privacy of a physician’s office.1 Buprenorphine can be dispensed for take home use, by prescription.1 This in addition to buprenorphine’s pharmacological and safety profile makes it an attractive treatment for patients addicted to opioids.2

Buprenorphine is different from other opioids in that it is a partial opioid agonist3. This property of buprenorphine may allow for;

  • less euphoria and physical dependence*3
  • lower potential for misuse*3
  • a ceiling on opioid effects*3
  • relatively mild withdrawal profile*3

At the appropriate dose buprenorphine treatment may:

  • Suppress symptoms of opioid withdrawal2
  • Decrease cravings for opioids2
  • Reduce illicit opioid use2
  • Block the effects of other opioids2
  • Help patients stay in treatment2

* When compared with full opioid agonists (such as oxycodone and heroin)3

Buprenorphine ('bu-pre-'nôr-fen) (C29H41NO4) is a semi-synthetic opioid derived from thebaine, an alkaloid of the poppy Papaver somniferum. Buprenorphine is an opioid partial agonist. This means that, although Buprenorphine is an opioid, and thus can produce typical opioid effects and side effects such as euphoria and respiratory depression, its maximal effects are less than those of full agonists like heroin and methadone. At low doses Buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms. The agonist effects of Buprenorphine increase linearly with increasing doses of the drug until it reaches a plateau and no longer continues to increase with further increases in dosage. This is called the "ceiling effect." Thus, Buprenorphine carries a lower risk of abuse, addiction, and side effects compared to full opioid agonists. In fact, Buprenorphine can actually block the effects of full opioid agonists and can precipitate withdrawal symptoms if administered to an opioid-addicted individual while a full agonist is in the bloodstream. This is the result of the high affinity Buprenorphine has to the opioid receptors. The affinity refers to the strength of attraction and likelihood of a substance to bind with the opioid receptors. Buprenorphine has a higher affinity than other opioids and as such will compete for the receptor and win. It will "knock off" other opioids and occupy that receptor blocking other opioids from attaching to it. If there is enough Buprenorphine to knock the opioids off the receptors but not enough to occupy and satisfy the receptors, withdrawal symptoms can occur; in which case the treatment is more Buprenorphine until withdrawal symptoms disappear.

In October 2002, the Food and Drug Administration (FDA) approved Subutex® (buprenorphine hydrochloride) and Suboxone® tablets (buprenorphine hydrochloride and naloxone hydrochloride) for the treatment of opiate dependence. These are the only buprenorphine based products approved to treat opioid dependence (addiction).

Suboxone, contains both buprenorphine and the opiate antagonist naloxone. Naloxone has been added to Suboxone to guard against intravenous abuse of buprenorphine by individuals physically dependent on opiates. If misused by injection, the naloxone will cause immediate withdrawal in opioid dependent people, however when taken sublingually, as indicated, the naloxone is clinically insignificant.

How buprenorphine works -- Graphics (PDF)

NAABT buprenorphine treatment brochure

buprenorphine-research

  1. U.S. Food and Drug Administration, FDA Talk Paper, T02-38, October 8, 2002, Subutex and Suboxone approved to treat opiate dependence
  2. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, Md: Substance Abuse and Mental Health Services Administration, 2004.
  3. Walsh SL, Eissenberg T. The clinical pharmacology of buprenorphine: extrapolating from the laboratory to the clinic. Drug Alcohol Depend. 2003;70(suppl 2):S13-S27


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What is the difference between "opioids" and "opiates"?
Opiates are drugs derived from opium. Opioids used to refer to synthetic opiates (drugs created to emulate opium, however different chemically). Now the term Opioid is used for the entire family of opiates including natural, synthetic and semi-synthetic.

An opioid is any agent that activates opioid receptors (protein molecules located on the membranes of some nerve cells) found principally in the central nervous system and gastrointestinal tract. There are four broad classes of opioids:
  • Endogenous opioid, naturally produced in the body, endorphins
  • Opium alkaloids, such as morphine and codeine
  • Semi-synthetic opioids such as heroin oxycodone, and Buprenorphine
  • Fully synthetic opioids, such as methadone, that have structures unrelated to the opium alkaloids
Medical professionals use the word "opioid" to refer to the entire family of opioids, and the word "opiate" for a specific non-synthetic opioid, however, many only use "opioid". Consistent with the current definition, this website uses "opioid" to refer to all opioids and opiates.

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What drugs are opioids?
Examples of opioids are: Painkillers such as; morphine, methadone, Buprenorphine, hydrocodone, and oxycodone. Heroin is also an opioid and is illegal.

Opioid drugs sold under brand names include: OxyContin®, Percocet®, Palladone®(taken off the market 7/2005), Vicodin®, Percodan®, Tylox® and Demerol® among others.

Drugs that are not opioids are; Cocaine, methamphetamines, ecstasy, LSD, GHB, Ketamine, other club drugs, or steroids.

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What’s this agonist / antagonist stuff?
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This is an important concept, it is why Buprenorphine is so unique as a treatment medication.

An agonist is a drug that activates certain receptors in the brain. Full agonist opioids activate the opioid receptors in the brain fully resulting in the full opioid effect. Examples of full agonists are heroin, oxycodone, methadone, hydrocodone, morphine, opium and others.

An antagonist is a drug that blocks opioids by attaching to the opioid receptors without activating them. Antagonists cause no opioid effect and block full agonist opioids. Examples are naltrexone and naloxone. Naloxone is sometimes used to reverse a heroin overdose.

Buprenorphine is a partial agonist meaning, it activates the opioid receptors in the brain, but to a much lesser degree then a full agonist.

Buprenorphine also acts as an antagonist, meaning it blocks other opioids, while allowing for some opioid effect of its own to suppress withdrawal symptoms and cravings.

This is why it would be misleading to classify buprenorphine as a replacement therapy. It would be equally misleading to classify it solely as an opioid blocker. Buprenorphine is in a category of its own and therefore should not be seen as “replacement” or "substitution" for anything else.



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How do opioids work in the brain?
Opioids attach to receptors in the brain. Normally these opioids are the endogenous variety that are created naturally in the body. Once attached, they send signals to the brain of the "opioid effect" which blocks pain, slows breathing, and has a general calming and anti-depressing effect. The body cannot produce enough natural opioids to stop severe or chronic pain nor can it produce enough to cause an overdose.

opioids can activate receptors because their chemical structure mimics that of a natural neurotransmitter. This similarity in structure "fools" receptors and allows the drugs to lock onto and activate the nerve cells. Although these drugs mimic brain chemicals, they don't activate nerve cells in the same way as a natural neurotransmitter, and they lead to abnormal messages being transmitted through the network.

Opioids target the brain's reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that regulate movement, emotion, cognition, motivation, and feelings of pleasure. The overstimulation of this system, which rewards our natural behaviors, produces the euphoric effects sought by people who misuse drugs and teaches them to repeat the behavior.

Our brains are wired to ensure that we will repeat life-sustaining activities by associating those activities with pleasure or reward. Whenever this reward circuit is activated, the brain notes that something important is happening that needs to be remembered, and teaches us to do it again and again, without thinking about it. Because drugs of abuse stimulate the same circuit, we learn to abuse drugs in the same way.

12/08

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Are there exceptions when Buprenorphine may be administered by a practitioner without the DATA 2000 waiver?
Yes. Under the Narcotic Addiction Treatment Act of 1974, all practitioners who use narcotic drugs for treating opiate addiction must obtain a separate registration under 21 U.S.C. Section 823(g)(1) or a DATA 2000 Waiver under 21 U.S.C. Section 823(g)(2). However, according to the Drug Enforcement Administration (DEA), an exception to the registration requirement, known as the "three-day rule" (Title 21, Code of Federal Regulations, Part 1306.07(b)), allows a practitioner who is not separately registered as a narcotic treatment program or certified as a “waivered DATA 2000 physician,” to administer (but not prescribe) narcotic drugs to a patient for the purpose of relieving acute withdrawal symptoms while arranging for the patient’s referral for treatment, under the following conditions: 1) not more than one day’s medication may be administered or given to a patient at one time; 2) this treatment may not be carried out for more than 72 hours; and 3) this 72-hour period cannot be renewed or extended.

The intent of 21 CFR 1306.07(b) is to provide practitioner flexibility in emergency situations where he or she may be confronted with a patient undergoing withdrawal. In such emergencies, it is impractical to require practitioners to obtain a separate registration. The 72-hour exception offers an opioid dependent individual relief from experiencing acute withdrawal symptoms, while the physician arranges placement in a maintenance/detoxification treatment program. This provision was established to augment, not to circumvent, the separate registration requirement. The three-day (72-hour) emergency exception cannot be renewed or extended. Because this is a Drug Enforcement Administration (DEA) rule, for further details consult DEA.

Print the 3 day rule

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How does Buprenorphine work in the brain?
Opioids attach to receptors in the brain, with three main effects; reduced respiration, euphoria, decreased pain. The more opioids ingested the more of an effect. The process of opioids binding to the opioid receptors can be thought of as a mechanical union, the better the fit the more the opioid effect. Buprenorphine is different. It too binds to the receptors, however, without a perfect fit. As a result the Buprenorphine tends to occupy the receptors without all of the opioid effects. The receptor is tricked into thinking it has been satisfied with opioids without producing strong feelings of euphoria, and without causing significant respiratory depression. This, in turn, prevents that receptor from joining with full opioids; therefore if the patient uses heroin or painkillers, they are unlikely to experience additional effect. Buprenorphine tends to stay with the receptors, blocking them, much longer then opioids do. This stickiness, is what makes Buprenorphine last so long, up to 3 days. watch a video

12/08

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Are there other uses for Buprenorphine?
The Food and Drug Administration (FDA) has approved Buprenex® ( an injectable formulation of buprenorphine) (Buprenex PI) to treat pain. However, by law, Buprenex cannot be used to treat opioid dependence(addiction), even by DATA-2000 wavered physicians. Buprenorphine: Considerations for Pain Management (study)

Buprenorphine has also been found to relieve refractory depression, but this particular use has never been approved by FDA. Refractory depression is depression that has not responded to other treatments. Some patients, who suffered from depression in the past, have experienced relief of symptoms on buprenorphine. (Bodkin,1995)

FDA has approved Subutex®( buprenorphine) and Suboxone® (buprenorphine/naloxone) to treat opioid dependence (addiction). However, neither Suboxone nor Subutex has been approved by the FDA for the treatment of depression or pain. Thus any use of Suboxone® and Subutex® for pain or depression is considered an off-label , unapproved use of these medications.

The D.E.A. articulates policy on the use of buprenorphine for pain and other off-label uses of buprenorphine products under DATA2000. Letter to Doctor Heit

Clarification: Buprenorphine is intended for the treatment of pain (as, Buprenex®) and opioid dependence (addiction) (as, Suboxone® and Subutex®). In 2001, 2005,and 2006 the Narcotic Addict Treatment Act was amended to allow qualified physicians, under certification of the DHHS, to prescribe Schedule III-V narcotic drugs (FDA approved for the indication of narcotic treatment) for narcotic addiction (up to 30 patients/physician at any time, 100 for those who meet certain criteria) outside the context of clinic-based narcotic treatment programs (Pub. L. 106-310). Suboxone® and Subutex® are the only treatment drugs that meet the requirement of this exemption (not Buprenex®). Source: DEA

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What exactly are opioid receptors?
These are protein molecules that exist on the surface of some nerve cell membranes. They provide a way for the body to experience the effects of opioids.

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What is addiction?
To understand fully you must be aware of the difference between tolerance, physical dependence, and addiction:

As a person takes opioids for an extended period of time, they become less sensitive to it and require more to achieve the same effect. Receptors in the brain become less sensitive. This means they need more and more opioid to achieve the same effect. This is called tolerance. When the body can no longer make enough natural opioids to satisfy the less sensitive receptors, the body becomes dependent on the external source. This is physical dependence.

"Physical Dependence" is a physiological state of adaptation to a substance, the absence of which produces symptoms and signs of withdrawal. It is possible to be physically dependent on a drug without being addicted to it. Physical dependence is the result of physical changes in the brain. It is not a matter of willpower rather it is actual physiology.

Addiction is defined as a behavioral syndrome characterized by the repeated, compulsive seeking (psychological dependence) or use of a substance despite adverse social, psychological, and/or physical consequences, along with the physical need for an increased amount of a substance as time goes on to achieve the same desired effect. Addiction is often (but not always, as with an addiction to gambling) accompanied by tolerance, physical dependence, and withdrawal syndrome.

People are dependent on water and food but are not addicted to them. If a cancer patient is taking large doses of painkillers, he/she will become tolerant and physically dependent on them (meaning they will experience withdrawal symptoms if the drug is abruptly removed) but they are not necessarily addicted to it (meaning they will not seek out the drug despite adverse consequences once the drug is no longer needed for pain).

Addiction is a disorder that requires treatment while physical dependence is not. This is important to understand in order to be able to discern between switching one addiction for another and treatment.

The American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine, recognizes these definitions below as the current accepted definitions.

I. Addiction:
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

II. Physical Dependence:
Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

III. Tolerance:
Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.

Summary:
Addiction is uncontrollable compulsive behavior caused by alterations of parts of the brain from repeated exposure to high euphoric responses.

Sources:

The Essence of Drug Addiction- By Alan I. Leshner, Ph.D., Former Director, National Institute of Drug Abuse, National Institutes of Health
http://www.nida.nih.gov/Published_Articles/Essence.html
http://www.naabt.org/tl/The_Essence_of_Addiction.pdf

What’s in a Word? Addiction Versus Dependence in DSM-V - CHARLES P. O’BRIEN, M.D., PH.D. NORA VOLKOW, M.D.
http://ajp.psychiatryonline.org/cgi/reprint/163/5/764

NIDA publication: The Neurobiology of Opioid Dependence: Implications for Treatment Thomas Kosten MD, Tony George MD http://www.nida.nih.gov/PDF/Perspectives/vol1no1/03Perspectives-Neurobio.pdf

The American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine - consensus document – February 2001, http://www.painmed.org/pdf/definition.pdf
American Academy of Pain Medicine - http://www.painmed.org/
American Pain Society - http://www.ampainsoc.org/
American Society of Addiction Medicine - http://www.asam.org/

1/09



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What is withdrawal?
Withdrawal syndrome consists of a predictable group of signs and symptoms resulting from abrupt removal of, or a rapid decrease in the regular dosage of, a psychoactive substance. The syndrome is often characterized by over activity of the physiological functions that were suppressed by the drug and/or depression of the functions that were stimulated by the drug. In other words, opposite of what the drug did. If the drug suppressed depression then the person would be depressed while in withdrawal. If the substance suppressed pain then the person will experience pain while in withdrawal.

Withdrawal from opioids can be severe and excruciating. Withdrawal generally begins between 4 to 72 hours after the last opioid use (depending on dose and opioid), The symptoms are both physical and emotional and include: dilated pupils, goose bumps, watery eyes, runny nose, yawning, loss of appetite, tremors, panic, chills, nausea, vomiting, muscle cramps, insomnia, stomach cramps, diarrhea, shaking, chills or profuse sweating, depression, irritability, jitters, and increased sensitivity to pain.

Withdrawal is a symptom of brain adaptations caused by some substances. As someone takes more and more of an opioid they increase their tolerance and require more and more to achieve the same effect. The level of tolerance where the body can no longer naturally compensate for the absence of the substance is called physical dependence. Withdrawal is a symptom of physical dependence. If you are not physically dependent on a substance you will not experience withdrawal from it. To achieve a comfortable transition off a medication you have become physically dependent on requires matching your taper off of the drug with your brain's ability to adapt to each decrease. Too fast will cause discomfort.

12/08

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Is continued addictive behavior a voluntary behavior?

The initial decision to take drugs is mostly voluntary. However, when drug misuse takes over, a person's ability to exert self control can become seriously impaired. Brain imaging studies from drug-addicted individuals show physical changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control. Scientists believe that these changes alter the way the brain works, and may help explain the compulsive and destructive behaviors of addiction.(1) The patient's struggle for recovery is in great part a struggle to overcome the effects of these brain adaptations.(3)

Behavior modification can help recondition the brain and reverse some of the brain changes, medication can sometimes help too, but often it is a combination of both. Not all of the brain adaptations resulting from addiction can be reversed, so patients need to develop strategies to compensate. Cognitive tools may be enough for some patients while others will require a combination of cognitive tools and medication to keep the addictive behavior in remission.(4)

1. NIDA, National Institute on Drug Abuse - Addiction: "Drugs, Brains, and Behavior - The Science of Addiction" 2008
3. Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Science & Practice Perspectives. 2002;1:13-20.
4. NAABT - http://www.naabt.org/education/behavior-modification-and-the-brain.cfm



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What are examples of treatment options?
1. Buprenorphine treatment

2. Methadone

3. In-patient detoxification

4. Rapid detoxification under general anesthesia

5. Self detoxification, also know as "cold turkey"

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What are the pros and cons of treatment with Methadone?
Pros:

  • More than 30 years of experience in treating opioid addiction
  • Daily visits give more structure to patients who need it
  • Cost is usually less and may be calculated on a sliding scale based on income
  • The opportunity to meet many people who share the same addiction
  • Group counseling is often provided
  • It is an opioid so it is able to stop the withdrawal symptoms
  • It lasts for at least 24 hours
  • There is no legal limit to how many patients a methadone clinic can treat
  • Without a ceiling effect doses can be increased as the patient becomes tolerant
Cons:
  • It is possible to continue to use illicit opioids while on methadone
  • Methadone treatment follows a strict protocol which makes some patients feel that they have no control over their own treatment
  • Shows up in urine testing for employment
  • Daily visits to the methadone clinic may be difficult for some patients who have jobs, especially when traveling distance is great.
  • Daily visits make overnight travel difficult for both business and pleasure
  • Some people find it difficult to overcome self-esteem issues in a clinic environment.


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What are the pros and cons of inpatient detoxification?
Medically supervised withdrawal from opioids is the first step to treatment, but it does not constitute treatment in and of itself. It is difficult to find data reporting the long-term outcomes of patients who have been treated with inpatient detoxification.

Pros:
Medical supervision and expertise is provided and patients are kept day and night until discharged. Usually they are given group counseling. Almost always patients are given medication to ease the withdrawal symptoms while they are hospitalized. Some people find it therapeutic to be away from home, jobs, family, friends, and their usual routines.

Cons:
Treatment is short term. Even thirty days it is often not enough. Most times the patient is discharged without medication and because cravings continue, most find it is a matter of time before they feel compelled to give into the cravings again and relapse. Removal from the drug-saturated environment does not in and of itself, help patients to learn coping skills for resistance in order to maintain recovery long term. It can be very expensive if not government funded or covered by insurance.

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What are the pros and cons of detoxification under anesthesia (Rapid Detox)?

Pros: Treatment is administered in the intensive care unit where there are experts available to mange the intense symptoms of the induced withdrawal such as seizures. The medical professionals who perform this method of detox are experienced in it.

Cons: It is not sufficient treatment for the brain disease of addiction. Detoxification is only the first step of a recovery, removing the opioids from the body does not do anything to treat the brain disease of addiction. Changes to the structure and function of the brain due to addiction may persist for months and if not treated usually result in relapse. Detox does not eliminate the cravings, and does not address the problems that lead to the addiction in the first place, unless psychosocial care is employed after the actual detoxification. It is physically dangerous, which is why it is done in an intensive care unit, and it is very expensive making it unavailable for most people. Modern addiction treatments have made a detoxification phase obsolete and not necessary, instead patients can transition directly to the treatment medications. It is difficult to find data that reports the long-term outcomes of patients who are treated with inpatient detoxification. Proponents offer their own selected patient survey results as their only evidence as to efficacy. This method of detoxification is often a high profit private enterprise. Real data as to actual efficacy especially over time is extremely difficult to obtain or validate. There is credible data that shows reasons not to use rapid detox.

In 2005 this was printed in the prestigious Journal of the American Medical association: "Rapid opioid detoxification with opioid antagonist induction using general anesthesia has emerged as an expensive, potentially dangerous, unproven approach to treat opioid dependence." (JAMA. 2005;294:903-913)

"In general, the data do not support using general anesthesia during detoxification," said Herbert Kleber, M.D., vice chair of APA's Council on Addiction Psychiatry and a coauthor of the report. "The critical thing is not what happens during detox, but what happens after, and we found no difference between the groups. In addition, there were serious life-threatening adverse effects in the anesthesia group."(Psychiatry News October 7, 2005)

"Anesthesia-assisted detoxification should have no significant role in the treatment of opioid dependence," wrote Patrick G. O'Connor, M.D., M.P.H., in an editorial accompanying the JAMA report..."When detoxification is provided to patients, other approaches using clonidine, methadone, or buprenorphine are likely to be at least as effective as anesthesia-assisted detoxification and also are safer and far less costly." (Psychiatry News October 7, 2005)

1/09

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What are the pros and cons of quitting on your own, also known as "cold turkey"?
It is not treatment for the brain disease of addiction; it does not take away the cravings, it does not address the problems that lead to the addiction in the first place; and after a period of time, it becomes too difficult to fight the cravings and withdrawal while simultaneously trying to rebuild your life damaged by addiction. Only 5% of the patients who quit cold turkey are successful long term. The successful 5% can have vocal advocates of this approach that don't accept that it may not work for everyone.

In the early stages of the disease patients can often quit cold turkey, experience acute withdrawal for a few days and emerge relatively symptom free. But as the disease progresses less severe longer lasting withdrawal symptoms persist long after the acute withdrawal has ended. This post acute withdrawal wears down patients and is often the cause of repeated relapse. The patient remembers being able to stop in the past and assumes they have weakened willpower and make attempts to quit over and over. They don't realize their brains have been changing as the disease progresses. Reversing, to the extent possible, the brain adaptations responsible for these symptoms of withdrawal is the focus of long term addiction treatment. Cognitive tools can be developed to deal with the remaining brain adaptations that cannot be reversed. (see the Neurobiology of Addiction)

Important Life Saving Alert!!

Perhaps one of the most frightening things about quitting and then having to give into the cravings at a later date is the mistaken belief that you can use the same amount of opioids as before. As you go through withdrawal your tolerance is lowered, meaning less substance will cause the same effect as more did prior to withdrawal. This is often the cause of a fatal overdose. Family members are shocked and devastated; “He was doing so great! He hadn’t used in several months. He was happy, etc, and suddenly he was found dead of an overdose!”

1/09

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Why is it called "quitting cold turkey"?
One symptom of opioid withdrawal is goose flesh (small bumps on the surface of the skin usually resulting from being cold). When someone discontinued opioids abruptly (cold turkey), they would exhibit these visible symptoms and it was noticed their skin looked like a cold turkey.

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Why is counseling an important tool in the treatment process?
Physical connections create pathways in the brain that can be altered when we learn something new. These changes to the brain can be seen with medical imagery. With long term difficult things like learning to play a musical instrument, these changes can be permanent. Addiction is a learned behavior that changes the brain as well. The brain becomes conditioned to want the substance. Through counseling and other behavioral modification we can actually, in some cases, change the brain physically. By changing our environment, starting a new job, new hobbies and friends, all will alter our brain in some way. It is possible to undo some of the changes that occurred while addicted. Therapy will recondition the brain closer to pre-addiction status. This will better prepare the patient for a time when they may no longer require medication.

Medication alone can reduce cravings and withdrawal, but recovering from an addictive disorder requires a rewiring of the brain and medication alone is not enough. Attention to eliminating things in life that cause stress or depression will help minimize the chance of relapse. Disassociating with friends who are in active addiction can be difficult but very necessary. An experienced counselor/therapist will be able to teach other techniques that will further help undo some of the brain changes and conditioned learning that occurred while becoming and once addicted.

It is important to find a counselor/therapist that is skilled in treating patients that employ medications in their treatment. Some counselors still dismiss the science behind addiction medicine because they may have been able to successfully end their addiction without it. They sometimes zealously focus on the singular approach that helped them and as a result may not be providing the best care for an individual who may require medication. It pays to find a counselor with a modern evidence-based philosophy of addiction treatment.

Counseling/therapy helps the patient rebuild relationships, repair finances, get a job, assume family responsibilities, decrease stress, anxiety and depression, and helps the patient make other meaningful changes in their lives that will allow them to achieve and maintain addiction remission. See: Behavior Modification and the Brain

1/09

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Who can prescribe Buprenorphine?
Any physician with a special "X" number issued by the DEA. The way the law is written, any doctor can prescribe Suboxone for treating pain, however the FDA has not granted approval for Suboxone to be used for pain, so it would be an off-label prescription. However there exists other restrictions for those who want to prescribe it for opioid addiction treatment (what the FDA approved it for). Doctors must take an 8-hour class on addiction treatment, or already possess such credentials, and then apply for a special DEA#. Once they obtain their # they are limited to treating only 30 patients at a time. (see our 30 patient limit page)

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Is buprenorphine addictive?

Although there is the potential for addiction to buprenorphine, the risk is low. Few people develop the dangerous uncontrollable compulsion to buprenorphine that we know as addiction. Buprenorphine will maintain some of a patient's existing physical dependence to opioids but that is manageable and can be resolved with a gradual taper once the patient is ready.

Amazingly despite 100% of people being treated for addiction with buprenorphine have demonstrated that they have a greater vulnerability to opioid addiction than the average person, very few become addicted to the buprenorphine, meaning very few lose control of their medication intake, nor experience uncontrollable compulsions and cravings toward the buprenorphine.

People can become addicted to anything that causes pleasure; consider gambling, sex, food, and internet. There is even a condition where patients drink so much water they dilute their blood, causing some level of intoxication (hyponatremia). They are addicted to this behavior, although water is not considered addictive. Substances and activities all have some potential addiction liability. Many factors including genetics and environment contribute to someone’s potential of becoming addicted

The brain has a natural reward system that helps us to learn that things that cause pleasure are good and should be repeated. This helps our species survive by reinforcing the desire for food and sex. These activities initiate a biochemical sequence and release dopamine in the brain. This feels good and is reinforced when repeated. Some substances can trick the brain and initiate the same biochemical sequence, but to a greater and unnatural degree. The brain senses this activity as the most pleasurable and hence the most necessary for survival, and creates a memory of the activity and cravings for more. The cycle reinforces itself and can lead to addiction (uncontrollable dangerous compulsive behavior)

Research has shown that substances that reach the brain faster have a higher potential for addiction. Also substances that provide a stronger effect cause more reinforcement. This begins a cycle of euphoria then craving then euphoria, craving and so on. Each time the cycle completes it reinforces a memory in the brain, the more frequent the cycle the more reinforcing.

The potential for addiction has to do with 3 main things, the speed of the onset, the level of reinforcement (pleasure), and the duration of action. IV heroin, is fast acting, strong euphoria, short duration. This gives it a high potential for addiction. Drugs with short intense cycles provide more potential for addiction than drugs with long “flatter” cycles.

Buprenorphine has a slow onset, mild effect, and long duration, which puts it at some risk of being addictive, more than water, but less than full agonist opioids, like heroin, morphine, oxycodone, and hydrocodone.

In countries where only Subutex is available (buprenorphine without the naloxone safeguard added), some people have injected their buprenorphine, thus decreasing the onset time and increasing euphoria, this in turn increased the potential for addiction and thus more people became addicted to it. The risk of addiction is less when taken sublingually as directed.


Further reading: Drug delivery methods, ranking addiction potential.

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Can someone switch from methadone to buprenorphine?
It is best to SLOWLY reduce your therapeutic dose of Methadone to 30 mg a day or less for at least a week, before discontinuing it completely for at least 36 hours before starting Buprenorphine. You MUST be in mild to moderate withdrawal before you take your first dose of Buprenorphine. If you are doing well in Methadone treatment it may not be advisable to change treatments at all unless you and your doctor determine it is in your best interest.

It is VERY important to follow these guidelines and prevent precipitated withdrawal.

What the experts say (PCSS mentors)

NAABT Precipitated Withdrawal sheet (including COWS)

8/07

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Does insurance cover it?
Most insurance companies cover the medication itself. However many people choose to pay for it themselves to keep their condition private. There are some doctors that will only take cash. It is one of the many unfair aspects of this disease. It pays to shop around. A doctor can choose what if any insurance they will accept (in some states). Every week more doctors are certified to prescribe. Some patients start with the first doctor they can get an appointment with,then find a more reasonably priced one later.

In the United States most physicians in private practice are for-profit businesses. Our free enterprise system allows them to charge what they feel the market will bare and it is up to the individual physicians to accept or not accept private insurance. If you do have insurance, many companies will allow you to submit the claim yourself for direct reimbursement. If your plan covers behavioral health conditions demand they pay your claim. Some insurance companies still feel that they can discriminate against people with addictive disorders. Most states have laws requiring insurance plans to cover addiction treatment. HBO addressed this in a documentary

How do I know if I'm paying too much?

12/08

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What if I miss a dose?
If you miss a dose and remember it hours later, take it upon remembering. If you forget until it is close to the time of the next day's dose, do not take a double dose. Not because you will take too much but rather you will just be wasting it, due to the ceiling effect. After being on treatment for a relatively short period of time you will feel so normal it may be difficult to remember unless you tie taking your medication to an activity you do every day at the same time. For example, after you have coffee or orange juice in the morning, or while reading the newspaper.

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Why are doctors limited to only helping 30/100 people at a time?
DATA-2000 was written to allow for a variety of new drugs to be used in an office based setting by certified physicians. In 2002 Suboxone/Subutex became the first drugs that physicians could use and as of May 2009 are still the only approved medications. Without knowing the abuse potential or other social impact of these yet to be discovered drugs for addiction safeguards were built in the law. Many patients and physicians have complained that the law is too restrictive because almost every physician can prescribe potentially addictive medication but once a patient becomes addicted physicians are restricted on how many they can treat for addiction.

The law has been amended twice. The first in August 2005 allowed every certified doctor to prescribe to up to 30 patients regardless of whether they are in a group or sole practice. Until then, a group practice had the same limit as a single practitioner, leaving large HMOs only allowed to treat 30 patients total regardless of how many doctors were certified. The second amendment was signed into law 12/29/2006 and allowed physicians who have had their DATA-2000 certification for more than one year the option of increasing their maximum to 100 patients. This change had a great impact on the number of patients that could get treatment.

See our page on the 30 limit for detailed information, and recent developments

5/09

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What if I need pain medication for surgery, or acute pain?
You will still be able to be treated for pain with elective dental or surgical procedures. Your doctors should speak with each other about the plan. They will likely stop your Buprenorphine medication, at least 36 hours before the procedure, and then when you are ready to go back on Buprenorphine you will need to be re-induced, which means stopping your pain medicine, experiencing mild withdrawal (for a very short time) and restarting your Buprenorphine.

What the PCSS Mentors recommend (print and bring to your doctor)

Your doctor can contact The SAMHSA-funded Physician Clinical Support System (PCSS) and consult one of the buprenorphine mentors.

Recommendations for Patients Receiving Maintenance Buprenorphine Therapy (Ann Intern Med. 2006;144:127-134. Acute Pain Management for Patients Receiving Maintenance Methadone or buprenorphine Therapy) (print and bring to your doctor)

Treatment options are as follows:

1. Continue buprenorphine maintenance therapy and titrate a short-acting opioid analgesic to effect. Higher doses of full opioid agonist analgesics may be required to compete with buprenorphine.

2. Divide the daily dose of buprenorphine and administer it every 6 to 8 hours to take advantage of its analgesic properties. However, these low doses may not provide effective analgesia in patients with opioid tolerance who are receiving OAT. Therefore, in addition to divided dosing of buprenorphine, effective analgesia may require the use of additional opioid agonist analgesics (for example, morphine).

3. Discontinue buprenorphine therapy and treat the patient with full scheduled opioid agonist analgesics by titrating to effect to avoid withdrawal. With resolution of the acute pain, discontinue the full opioid agonist analgesic and resume maintenance therapy with buprenorphine, using an induction protocol.

4. Convert patient from buprenorphine to methadone at 30 to 40 mg/d. At this dose, methadone will prevent acute withdrawal in most patients.

 

In case of emergency, for those maintained on Buprenorphine

We never know what could happen. What if there is an emergency and you need to be treated for pain? Worse yet what if you are unconscious? A potential problem is you could be unnecessarily under-treated for pain. Since many doctors out there are still unfamiliar with Buprenorphine, there are a few documents that will be helpful. We suggest you print out a few of these and tell a loved one or your “in case of emergency” person, where they are.

Keep this in a folder, jump drive, or CD, just in case of emergency. Hopefully it will never be needed.

Most of these files are PDF files and require the standard reader to view them. This comes with newer computers but if these files don’t open for you, you can download the free and virus free reader here. This is something you only have to do once and will allow you access to all kinds of information as the pdf file format is becoming more and more popular. http://www.adobe.com/products/acrobat/readstep2.html

 



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How soon can a work schedule be resumed?
It is recommended to take the first day of treatment off. Some are able to work even on Day One. Certainly after Day One, you should be able to work with greater attentiveness and clarity than before starting treatment. The transition from addictive substance to Buprenorphine is usually painless and most patients experience no adverse physical effects. In fact most say that they feel normal again, like they were never on drugs at all.

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What is the DATA 2000?
The Drug Addiction Treatment Act of 2000 (DATA 2000)

It enables qualified physicians to prescribe and/or dispense narcotics for the purpose of treating opioid dependency. For the first time, physicians are able to treat this disease from their private offices or other clinical settings. This presents a very desirable treatment option for those who are unwilling or unable to seek help in drug treatment clinics. Patients can now be treated in the privacy of their doctor’s office, as are other people being treated for any other type of medical condition. One medicine doctors may now prescribe is Buprenorphine. The major downfall of this Act is the limitation of 30 patients per physician. Read the entire act at: http://www.naabt.org/30_patient_limit.cfm

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What is the Naloxone for?

(In relation to the Buprenorphine/Naloxone Combination product(Suboxone®))
Because of reports of misuse of buprenorphine by injection in other countries, the buprenorphine/naloxone combination was developed for the U.S. market. This combination was thought to decrease the potential for diversion and misuse of buprenorphine because, if injected, the naloxone should precipitate withdrawal in the patient.

Sublingually, naloxone has a relatively low bioavailability while buprenorphine has good sublingual bioavailability.
Both have poor bioavailability through the GI tract. Taken sublingually, as directed, naloxone is clinically insignificant and has virtually no effect. (Except in rare cases of an allergic reaction or naloxone hypersensitivity.)

The safety and efficacy profile of sublingual buprenorphine/naloxone appears to be equivalent to that of buprenorphine alone (Harris et al. 2000).

Sources:

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction
A Treatment Improvement Protocol TIP40 TIP 40, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment
www.samhsa.gov, page 23

FDA. Full Prescribing information on Subutex® (buprenorphine)/Suboxone® (buprenorphine/naloxone)
http://www.suboxone.com/pdfs/SuboxonePI.pdf

naloxone: Brand name: Narcan. An opioid antagonist, similar to naltrexone, that works by blocking opioid receptors in the brain, thereby blocking the effects of opioid agonists (e.g., heroin, morphine). Naloxone has poor bioavailability when taken sublingually. Naloxone has a high afinity to the mu opioid receptor, yet not as high of an affinity as buprenorphine, at the mu receptor. source: http://www.naabt.org/glossary.cfm#N

In the absence of narcotics or agonistic effects of other narcotic antagonists it exhibits essentially no pharmacologic activity. Naloxone has not been shown to produce tolerance nor to cause physical or psychological dependence.
In the presence of physical dependence on narcotics Naloxone will produce withdrawal symptoms.
Source: http://www.drugs.com/pro/naloxone.html



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Is Buprenorphine safe for people with a co-existing psychological illness?
Many people use drugs because they are knowingly or unknowingly self-medicating for an underlying psychiatric condition. In either case, once the addiction is being treated the psychiatric condition will surface and require treatment. This patient would be well served by getting Buprenorphine treatment through an addiction psychiatrist or a psychiatrist who specializes in the illness with which the patient is afflicted.

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What are the statistics with regard to opioid addiction and use in the US?
According to the January 2003 Drug Abuse Warning Network (DAWN) Report published by SAMHSA's OAS, the incidence of abuse of prescription opioid pain medications (also known as narcotic analgesics) such as hydrocodone and oxycodone has risen markedly in recent years (Crane 2003). From 1994 to 2001, there was a 117% increase in emergency room visits related to opioid analgesic abuse. According to the DAWN Mortality Data Report for 2002 (SAMHSA 2002), hydrocodone ranked among the 10 most common drugs related to deaths in 18 cities. Oxycodone ranked among the 10 most common drugs related to deaths in 19 cities, including Philadelphia (88), Baltimore (34), Boston (34), Phoenix (34), and Miami (28).

According to the Office of National Drug Control Policy (ONDCP), there were an estimated 810,000 to 1,000,000 individuals addicted to heroin in the US in the year 2000 - which is the highest number since the mid-to-late 1970s (ONDCP 2003). Several factors have contributed to this increase. Historically, heroin purity has been less than 10 percent. By the late 1990s, however, purity was between 50 and 80 percent.

Because individuals can become addicted to or overdose from heroin taken via any route, the increase in the type and number of routes used has lead to a rise in new cases of heroin addiction across all socio-demographic categories.

The rise of heroin use appears to be a national phenomenon in the United States. Heroin overdose deaths have risen sharply, as have emergency department admissions involving heroin. The most recent data comes from SAMHSA's DAWN reports, which can be accessed via the web at the following sites:

http://dawninfo.samhsa.gov

http://www.nida.nih.gov/CEWG/DAWN.html

http://oas.samhsa.gov/

http://www.usdoj.gov/dea/pubs/state_factsheets.html

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What is Precipitated withdrawal?
Precipitated withdrawal can occur when an antagonist (or partial antagonist, such as buprenorphine) is administered to a patient dependent on full agonist opioids. Due to Buprenorphine’s high affinity but low intrinsic activity at the mu receptor, the partial antagonist displaces agonist opioids from the mu receptors, without activating the receptor to an equivalent degree, resulting in a net decrease in agonist effect, thus precipitating a withdrawal syndrome.

It is a common misconception that the Naloxone in Suboxone initiates precipitated withdrawal. This is false. The Naloxone can only initiate precipitated withdrawal if injected into a person tolerant to opioids. Taken sublingually the Naloxone has virtually no effect.

How to avoid precipitated withdrawal:
The best way to avoid this condition is through patient education. The patient should be informed, prior to the induction appointment, of what precipitated withdrawal is and how they can avoid it. The patient who understands that under reporting last use puts him/her at high risk for rapid and intense onset of withdrawal syndrome, is more likely to accurately report last use. Ask the patient what their first few symptoms and signs of withdrawal have been in the past. Look for these S/S before administering the first dose at induction.

Precipitated withdrawal puts the patient at risk for concluding that Buprenorphine is ineffective, or the doctor may not know how to help, or both. Either situation leaves the patient in a precarious state physically and emotionally.

Begin the induction by assessing last use of all Opioids, short and long acting, objective and subjective symptoms and calculate a COWS score. If not in sufficient withdrawal explain that it is in the patient’s best interest to wait.

Short-acting Opioids:
(Heroin, Crushed OxyContin®, Percocet®, Vicodin®, Oxycodone®)
Short- acting Opioids have a half life of approximately 8 hours or less. Prior to induction, patients must abstain from all short-acting Opioids for 12 to 24 hours and/or have objective withdrawal symptoms sufficient to produce a score of 5 to 6 on the COWS (Clinical Opiate Withdrawal Scale) such as dilated pupils.

Methadone;
Patients transitioning from methadone to Buprenorphine require a slow taper to 30mg./day of methadone, for at least one week. Last dose must be no less than 36 hours prior to induction. A minimal score of at least 5 to 6 on COWS is recommended.

OxyContin® (taken orally)
Discontinue use for at least 24 hours prior to induction, with a COWS score of at least 5 to 6.

How to Treat Precipitated Withdrawal
If the patient experiences precipitated withdrawal, administer additional 2mg. to 4 mg. doses of Buprenorphine hourly, until symptoms dissipate.

Clinical Opiate Withdrawal Scale (COWS) scale

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Naltrexone? What is it and what does it do?
A narcotic antagonist, works by blocking opioid receptors in the brain, without activating them, therefore, blocking the effects of opioids (e.g., heroin, morphine). Naltrexone has a High affinity to the Mu receptor, yet not as high as buprenorphine. Naltrexone was first synthesized in 1965. It was approved by the FDA in 1984 for preventing relapse in opioid addicted patients. Later in 1994 the FDA approved it to treat alcoholism, it tends to reduce cravings for alcohol. Naltrexone binds to the opioid receptors stronger then other opioids (except buprenorphine) this results in near complete blocking of opioids. Naltrexone is not used extensively because the retention rate of patients is very low. Unlike buprenorphine Naltrexone does not activate the opioid receptors at all, so any lingering withdrawal, or pain from a compromised endogenous opioid system will still exist.

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Where can my doctor get help in using buprenorphine?
www.pcssmentor.org The SAMHSA-funded PCSS is designed to assist practicing physicians, in accordance with the Drug Addiction Treatment Act of 2000, in incorporating into their practices the treatment of prescription opioid and heroin dependent patients using buprenorphine.

The PCSS service is available, at no cost, to interested physicians and staff, to assist in implementing office-based treatment of opioid dependence with buprenorphine. The essential elements of the PCSS are a national network of trained physician mentors with expertise in buprenorphine treatment and skilled in clinical education, who will be supported by NATIONAL EXPERTS in the use of buprenorphine.

The PCSS MENTORS are members of medical specialty societies and provide mentoring support and educational services based on evidence-based practice guidelines. The efforts of PCSS are coordinated by a STEERING COMMITTEE composed of representatives from the Federal government, the leading addiction medicine societies, along with primary care and psychiatric organizations that represent the target physician populations.

To register as a PCSS Participant, you may contact the PCSS directly or download, complete, and return the PCSS Participant Registration Questionnaire form. The PCSS staff will match you to a mentor within 2 days of receiving your registration form.

EMAIL: PCSSproject@asam.org

PHONE: 877.630.8812

FAX: 301.656.3815



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Is my medical information confidential?
Untitled Document

Confidentiality of Alcohol and Drug Dependence Patient Records (summary)

The confidentiality of alcohol and drug dependence patient records maintained by a practice/program are protected by federal law and regulations. Generally, the practice/program may not say to a person outside the practice/program that a patient attends the practice/program, or disclose any information identifying a patient as being alcohol or drug dependent unless:

  • The patient consents in writing;
  • The disclosure is allowed by a court order, or
  • The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or practice/program evaluation.

Violation of the federal law and regulations by a practice/program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.

Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/program or against any person who works for the practice/program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

Privacy and Your Health Information Fact Sheet:

Your Health Information Privacy Rights Fact Sheet:

THE CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS REGULATION AND THE H.I.P.A.A. PRIVACY RULE: SAMHSA

Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2)

Summary of Patients' Right to Privacy (suboxone.com)

H.I.P.A.A. Website

sample consent form (MS-WORD)

How to file a health information privacy complaint



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Does buprenorphine show up in an employer drug screening?

Buprenorphine has to be specifically tested for and isn’t commonly included on standard drug screen panels. Buprenorphine will NOT cause a positive result on tests for other opiates. The typical urine tests used to detect methadone, oxycodone, heroin, and other opioids check for a different metabolite than that found with buprenorphine and will not show a positive result in buprenorphine (only) maintained patients.

There are in-office tests specifically for buprenorphine that will detect it. These tests are not common but can be purchased on the internet, however we know of none that are CLIA-waved.

When reading in-office dip-strip tests be aware that faint lines are not ‘false positives” see this image of how to read this type of test correctly, and follow the manufacturer instructions: Reading test results

A typical employer multi drug screen might consist of a test for Amphetamine (AMP); Barbiturates (BAR)(Phenobarbital, Secobarbitol, Butalbital); Benzodiazepines(BZO)(Valium, Xanax, Librium, Serax, Rohypnol); Cocaine (COC); Marijuana (THC); Methylenedioxymethamphetamine (MDMA)(Ecstasy); Opiates (OPI); Oxycodone (OXY); Phencyclidine (PCP); Propoxyphene (PPX)(Darvon compounds); and Tricyclic Antidepressants (TCA)

Employers that expand their tests might include some of the following: Hydrocodone (Lortab, Vicodin), Methaqualone (Quaaludes), Methadone, Ethanol (Alcohol)

It is very unusual for an employer to test for buprenorphine, at least for now.

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