Buprenorphine Replacement for Heroin
If you stop taking heroin, buprenorphine can prevent or reduce the unpleasant withdrawal symptoms. Many people stay on buprenorphine long-term but some people gradually reduce the dose and come off drugs altogether. You should not take any street drugs or much alcohol when you are taking buprenorphine.
What is heroin addiction?
If you are addicted to heroin it means that you develop withdrawal symptoms within a day or so of the last dose. So, if you are addicted to heroin you need a regular dose to feel 'normal'.
Withdrawal symptoms can include:
- Feeling hot and cold.
- Runny eyes and nose.
- Being off food.
- Stomach cramps.
- Feeling sick (nausea) or being sick (vomiting).
- Poor sleep.
- General aches and pains.
- Just feeling awful.
Withdrawal symptoms tend to ease and go within five days. However, you may then have a persistent craving for heroin, remain tired and have poor sleep for quite some time afterwards.
What is buprenorphine?
Buprenorphine is an opioid drug that is similar to heroin. It can be prescribed. If you take buprenorphine, you are unlikely to develop withdrawal symptoms if you stop heroin (or the withdrawal symptoms are much less severe). It also helps to reduce cravings for heroin. The drug most commonly prescribed as a substitute for heroin is methadone. On average, methadone tends to work better than buprenorphine in helping people to keep off heroin. However, buprenorphine is still a good treatment and some people prefer it because:
- They feel more 'clear-headed' with buprenorphine than with methadone.
- They have difficulties using methadone.
- Buprenorphine tends to be easier to come off ('detox') than methadone. Some people take methadone long-term for 'maintenance' but switch to buprenorphine if they decide to 'detox'.
- Buprenorphine is possibly safer if taken in overdose than methadone.
If you take buprenorphine (or methadone) under supervision from a doctor instead of street heroin, you are:
- More likely to be able to get away from the street 'drug scene'.
- Likely to feel better in yourself.
- More likely to be able to get off drugs for good.
Who prescribes buprenorphine, and when?
Many GPs will refer you to a community drug team to be assessed. Following assessment, the community drug team may prescribe buprenorphine. Some GPs work in a 'shared care' arrangement and will prescribe whatever is recommended for you by a community drug team. Some GPs who are specially trained may assess and prescribe buprenorphine without the need for referral.
This usually includes:
- Taking details of your health and social circumstances.
- Taking details of your past and current drug taking and whether buprenorphine is needed or appropriate.
- An examination.
- A urine test (or a mouth swab test) to confirm the drugs you are taking.
- An assessment of what you think you need at this present time.
If you have been injecting drugs such as heroin, it is also common to advise:
- A blood test which includes testing for HIV, checking the health of your liver (liver function tests) and checking for hepatitis A, B and C.
- Immunisation against hepatitis A, hepatitis B and tetanus (if not previously immunised).
- If appropriate, immunisation against hepatitis B for your partner and children.
- About the dangers of injecting, of using shared needles and syringes and on other ways to reduce harm to yourself.
Starting off with buprenorphine
Buprenorphine is usually started some time after assessment when the results of the urine test are back. An initial dose is chosen, depending on current usage of heroin (or methadone).
Buprenorphine is a tablet which you put under your tongue. The tablet dissolves over 3-7 minutes and is absorbed straight into the bloodstream from your mouth. (The tablets do not work if you swallow them into the stomach.) It is usually prescribed as a once-daily dose. You will usually be asked to take it under the supervision of the pharmacist who dispenses the buprenorphine to you. This means there can be no doubt about how much you take at each dose. This supervision may be relaxed after a few months if you are taking a regular maintenance dose. The taste of buprenorphine can be quite bitter.
The first dose
The timing of the first dose is important.
- If you are taking heroin - you take the first dose of buprenorphine at least eight hours after taking your last dose of heroin.
- If you are taking methadone - you take the first dose of buprenorphine between 24 and 36 hours after your last dose of methadone.
The reason for these timings is because, for buprenorphine to work well, you need to take it when your body has low levels of heroin or methadone. So, the aim is to take the first dose only when you feel some withdrawal symptoms starting. This tends to be about eight hours after the last dose of heroin and longer after the last dose of methadone. If you take buprenorphine sooner, it can actually cause withdrawal symptoms suddenly to develop.
Getting to the right dose
The initial dose will usually need to be increased. You will usually be given a higher dose on the second and third days, by which time you should not be feeling any withdrawal symptoms. It is very important that you do not take any heroin or methadone during this time, as this will cause you to feel ill - as though you are withdrawing. Your dose may need to be increased again to prevent symptoms of craving but most people feel they have the correct dose within the first week.
Maintenance and coming off ('detox')
Once established on a regular dose, most people stay on buprenorphine for a long period of time or even long-term. This is called maintenance and helps you to keep off street drugs. Some people gradually reduce the dose and come off it. This is called detoxification, or 'detox'. However, it usually takes several months and sometimes years, before most people are ready to consider 'detox'. It is often safer to stay on buprenorphine than to 'detox' before you are ready.
Buprenorphine has been combined with another medicine called naloxone (brand name Suboxone®). It has been produced in the form of a tablet which is dissolved under the tongue. Naloxone blocks the action of buprenorphine and the effect of the combination is that, if a person is tempted to take more than the recommended dose (particularly if they crush the tablet and try to inject it), they will start to have withdrawal effects.
Some other points about taking buprenorphine
- Some people feel uncomfortable during the first 2 to 3 days. Do not be tempted to take heroin on top.
- Some other medicines may interfere with buprenorphine - for example, some antidepressants. Tell the doctor who prescribes buprenorphine if you are taking any other medicines. However, most prescribed medicines can be taken in the normal way.
- You are more likely to succeed in staying off heroin if you have support and counselling in addition to taking buprenorphine or methadone. This may be from a local drug community team (or similar). Self-help groups or other agencies may also be of help. It is much harder to 'do it alone' - so do go for counselling and help if it is available in your area.
- You will be asked to give a urine sample from time to time by the prescribing doctor.
- Other street drugs such as benzodiazepines ('benzos') and alcohol can also affect buprenorphine. So, it is best not to take any other drugs and don't drink too much alcohol.
- Driving. If you use heroin or other opiates such as buprenorphine, you should inform the Driver and Vehicle Licensing Agency (DVLA). You are likely to be banned from driving. However, if you are on a supervised buprenorphine programme, you may be allowed to drive again subject to an annual review.
- Pregnancy. If you become pregnant you should not suddenly stop your buprenorphine withdrawal programme. It is riskier to stop buprenorphine suddenly than to continue on your regular dose. Discuss the situation with your doctor. If you are taking buprenorphine combined with naloxone, you may be advised to switch to buprenorphine without naloxone. Studies suggest it is safer to continue with buprenorphine until the baby is born. However, if you want to stop it during pregnancy, the risk of withdrawal problems is lowest in the 3-6 months (the second trimester).
- Keep buprenorphine and any other drugs out of reach of children.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines, you can report this on the Yellow Card Scheme. You can do this online at the following web address: www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that your medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:
- The side-effect.
- The name of the medicine which you think caused it.
- The person who had the side-effect.
- Your contact details as the reporter of the side-effect.
It is helpful if you have your medication and/or the leaflet that came with it with you while you fill out the report.
Further reading & references
- Opioid dependence; NICE CKS, April 2015 (UK access only)
- Evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP; British Association for Psychopharmacology (May 2012)
- Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care; Royal College of General Practitioners (2011)
- Drug misuse and dependence UK guidelines on clinical management; Dept of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive (2007)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr John Cox