healthy man after sub-acute medical detox

Sub-Acute Medical Detox: Subutex in Early Recovery

The first step on an addiction recovery journey might possibly a sub-acute medical detox. A detoxification under medical supervision helps the body slowly and carefully wean off substances. A medical detox safely controls any potential withdrawal symptoms that can be painful and possibly life-threatening.

What Is Sub-Acute Medical Detox?

An acute medical condition means it is a critical situation that needs immediate attention. Sub-acute indicates that the condition is somewhere between acute and chronic (a condition that is long-term or persistent).

In cases where the substance use disorder is not at the level healthcare professionals consider to be acute, a sub-acute detoxification program may be the best option. This way, the appropriate level of care to start a successful recovery is accessed without the restrictions of acute care.

When the term sub-acute is applied to a medical detox, it generally means that the person who undergoes it has low risks of developing serious complications during detox, has relatively good overall physical health, and there are no or mild coexisting psychiatric illnesses.

where does sub-acute medical detox happen?

When placed in a sub-acute detox program, there are a variety of environments for care, which may include:

  • Residential detox facility

  • Urgent care center

  • Intensive outpatient program (IOP)

  • Doctor’s office

The ideal setting depends on the level of monitoring that ensures the detox occurs in a controlled and safe way. When living in a residential facility during the detox, it does not mean that it’s the only activity. Much of time during detox there is traditional and alternative therapies, and physical activities. In other detox settings, people live at home during the sub-acute detox and come in for a series of monitoring appointments.

Many sub-acute opioid detox programs use a prescription medication called Subutex.

Sub-Acute vs. Acute Medical Detox?

An acute medical detox involves around-the-clock monitoring of the person in detox. An acute medical detox is indicated for people who have:

  • Serious medical conditions

  • Severe co-occurring psychiatric illnesses

  • High risks for severe withdrawal symptoms

  • Life-threatening complications

  • Severe addiction to more than one substance

When the indications for an acute medical detox are not present, a sub-acute medical detox may be more appropriate. In some cases, a sub-acute medical detox may follow an acute medical detox.

A Brief History of Sub-Acute Medical Detox Using Subutex

What is Subutex?

Subutex (generic name: buprenorphine) is a semi-synthetic opioid that is used to treat opioid drug dependence, addiction to opioids, as well as acute or chronic pain. It is administered under the tongue (sublingual), transdermal (via a skin patch), by an implant, or by injection.

Prior to the year 2000, doctors were not permitted in an office-based setting to use medications to manage opioid substance use disorders using opioids. When the Drug Addiction Treatment Act of 2000 was passed it permitted doctors to prescribe buprenorphine (the generic name for Subutex) to people in settings such as urgent care centers, IOP programs, and doctor’s offices. The doctor must first get a waiver to prescribe buprenorphine for the treatment of opioid addiction or dependence.

Alternatives to Subutex

The only other two approved medications for opioid substance abuse management that are permitted by law are: methadone and LAAM (levacetylmethadol). Both medications are required by law to be administered within a highly regulated methadone clinic.

Political Changes

Prior to the year 2000, doctors were not permitted in an office-based setting to use medications to manage opioid substance use disorders using opioids. When the Drug Addiction Treatment Act of 2000 was passed it permitted doctors to prescribe buprenorphine (the generic name for Subutex) to people in settings such as urgent care centers, IOP programs, and doctor’s offices. The doctor must first get a waiver to prescribe buprenorphine for the treatment of opioid addiction or dependence.

The only other two approved medications for opioid substance abuse management that are permitted by law are: methadone and LAAM (levacetylmethadol). Both medications are required by law to be administered within a highly regulated methadone clinic.

rates of opioid abuse

 

  • More than 2.5 million people struggled with opioid abuse in 2014.​​​1

  • There were more than 28,000 overdose deaths involving opioids in 2014.

  • Opioid overdose deaths continued to rise through 2017 when there were more than 47,000 deaths.​​​2

  • 3 out of 4 drug overdoses are caused by opiates.​​​3

  • Each day, approximately 130 people die from opioid overdose. ​​​2

  • The Centers for Disease Control (CDC) estimates that each year the total economic costs due to just prescription opioid misuse in our nation is $78.5 billion a year. This figure includes costs of lost productivity, healthcare, addiction treatment, and crime.

  • Opioid prescriptions have risen from 76 million in 1991 to approximately 207 million in 2013.​​​4

  • Globally, the United States accounts for almost 100% of the total hydrocodone prescriptions in the world and 81% for oxycodone.

%

The United States accounts for 81% of Oxycodone prescriptions

Opioid Withdrawal Symptoms

Individuals facing opioid addiction have many challenges to overcome. If they suddenly stop taking opioids, it usually results in uncomfortable and potentially life-threatening withdrawal reactions. The cravings for opioids and other withdrawal symptoms can last for weeks or months after the last opioid dose and may include:

  • Severe muscle cramps
  • Abdominal cramps
  • Severe diarrhea
  • Runny nose
  • Teary eyes
  • Fever
  • Excessive yawning
  • Goosebumps
  • Elevated blood pressure
  • Pupil dilation
  • Rapid heart rate
  • Problems maintaining body temperature
  • Other complications can develop if comorbid medical illnesses are present

The length of withdrawal symptoms depends on various factors like the type of drug, frequency of use, and your overall health. For example, withdrawal symptoms for heroin may start as soon as 12 hours from last use, while withdrawal symptoms for methadone may start after a day and a half.
Withdrawal symptoms may reoccur during the recovery process. Many experts feel that symptoms may reappear until the patient has six months of total abstinence.

 

Buprenorphine vs. Methadone for Opioid Addiction

One of the solutions to help alleviate the opioid crisis involves discovering new and better ways to treat opioid use disorders. Opioid maintenance therapy using medications is one effective way to reduce or eliminate illicit and legal opioid use in people struggling with addiction. Effective medications used to treat opioid addiction include buprenorphine (Subutex) and methadone.

Methadone Treatment

In the United States, the primary medication treatment traditionally used was methadone. However, methadone treatment programs are highly regulated by federal law, have stringent criteria for entry, and many programs have long waiting lists.

Buprenorphine TREatment

In October 2002, the FDA approved buprenorphine to treat opioid substance use disorders to help people recover from addiction.​​​5 Buprenorphine is a semi-synthetic opioid made from opium poppy. Buprenorphine is a partial agonist, which means it starts a physiological response when combined with a receptor.

Buprenorphine affects the opioid receptors in the brain and body, but because it is a partial agonist, there is a ceiling of how much it activates a receptor. There is only a certain level buprenorphine can work on a receptor, meaning euphoria and a “rush” are not possible when buprenorphine is taken as intended. By comparison, methadone (a full agonist) exerts a much higher level of activation. Buprenorphine also detaches from receptors slowly, so there is no noticeable “let down”. All these buprenorphine properties together allow the medication to prevent withdrawal reactions, block the effects of other opioids taken after buprenorphine, and it also allows for its effects to last longer.

The method by which a person takes buprenorphine determines its effectiveness. Buprenorphine is most readily absorbed through mucous membranes, making under the tongue administration a convenient way to treat opioid dependence during a sub-acute detox.

Assessment for Sub-Acute Medical Detox?

A sub-acute medical detox may be a better fit versus an acute medical detox when the person is assessed on the following factors and the findings are as follows:

Acute Intoxication and/or Withdrawal Potential

When the potential for acute intoxication and withdrawal reactions are low, a sub-acute detox may suffice.

Medical Conditions and the Risks for Complications

When the person has little or no serious medical conditions, and thus is at low risk for complications, a sub-acute detox may be a better fit.

Co-occurring Conditions and Complications

When an individual has none or mild emotional, cognitive, or behavioral coexisting conditions, a sub-acute detox may be recommended.

Readiness to Change

A sub-acute medical detox may be the best choice for a person who demonstrates a high degree of readiness to change. By contrast, a person who is being forced into detox, for example by court order, may not have a readiness to change and therefore would need an acute detox that offers 24/7 monitoring.

Relapse Potential

An assessment for relapse shows that a person has a low risk of returning to substance use makes sub-acute medical detox a good fit.

Recovery Living Environment

An assessment about where the person would be living during a sub-acute medical detox is an important factor in deciding if sub-acute or acute medical detox is needed. If the individual has a stable living environment, such as a sober living home or a residence that is free of substances, a sub-acute medical detox may be the appropriate level of care. If the individual is homeless or lives in an environment that is unstable, or lives where drug or alcohol use is present, an acute medical detox may be the best choice.

Additional Factors to Consider

Other factors that make a sub-acute medical detox a good choice is if the person being treated demonstrates an ability to keep treatment appointments, and if they have a supportive person involved that can assist them on a regular basis.

Misconceptions About Subutex Treatment

Misconception #1 Taking a semi-synthetic opioid like Subutex simply trades one addiction for another:

According to The National Alliance of Advocates for Buprenorphine Treatment (NAABT.org), successful treatment using Subutex means the signs and symptoms of addiction are no longer present. The cravings, compulsions, and loss of control over drug use have disappeared when a person is taking Subutex. Rather than labeling Subutex treatment as a “switch in addiction”, it is viewed as putting addiction into remission.​​​7

Misconception #2 You can easily get addicted to Subutex just like any other opioid:

While there is a potential risk for addiction to Subutex, the risk is low. According to NAABT, few people develop the uncontrollable and detrimental compulsion to Subutex.7 While Subutex does maintain some of an individual’s existing physical dependence to opioids, the dependence is manageable with a gradual taper down at the proper time.

Fact: Sub-Acute Detox Is the First Step in “Whole Person” Treatment

A medical detox of any kind is not meant as a standalone treatment. The rates for relapse are high immediately after detox, so it is important for treatment to continue.

One study found that following their last detox:​​​8

  • 40% Of people relapsed in less than a week 40% 40%
  • 39% Of people relapsed in more than a week 39% 39%

These high rates of relapse indicate that it is vitally important that other evidence-based treatment methods are started during detox and continue afterwards. Other treatment methods can include intensive outpatient programs, 12-step groups, as well as individual and group counseling sessions.

Finding Medical Detox

If you are concerned that you or a loved one has an addiction or substance use disorder, medical detox that uses Subutex may be the first step on the path to recovery. The best option may be a full service, specialized treatment center that offers medical detox and has a full program of options for follow-up treatment. Nurse practitioners and physician assistants have become eligible to prescribe Subutex, and many of these healthcare professionals can be found in detox and treatment centers. 

The disadvantage of going to a private doctor is that it may be beyond their scope to set up a formal addiction treatment plan, such as intensive outpatient and/or 12-step programs, as well as individual and group counseling sessions. Another disadvantage of seeking help from a doctor is that those with certification for Subutex treatment can have a maximum of 275 patients, the number of available providers is limited. 

Check with your health insurance company regarding your prescription coverage for Subutex to set your expectations about the expenses.  

Assessment and Intake Process

The first step is an evaluation that involves medical professionals conducting an assessment regarding the person’s mental state and any medical issues. A drug history is conducted. Drug testing is also performed to determine what and how much alcohol and/or drugs are present in the body. 

Using this information, healthcare professionals can help determine the appropriate level of care necessary for you or your loved one: acute or sub-acute. Healthcare professionals will then help outline a specific plan for the detoxification process. 

Either a sub-acute or full detox can be a first step on the recovery path leading to a life free from drug or alcohol addiction.

Sub-Acute Detox Helps Prepare for and Maintain Long-Term Recovery

Subutex can be used for long-term maintenance of sobriety and/or for a medically supervised sub-acute opioid detox. Research evidence suggests that after a sub-acute detox, the use of opioid-based maintenance treatments show higher success rates than detox alone.​​​6 The initial steps in this process are stabilizing the person and cultivating abstinence from opioids, which can be accomplished during a sub-acute medical detox.

Research also shows that Subutex is well accepted by people for short period withdrawal and that opioid withdrawal signs and symptoms are suppressed. The effectiveness of a sub-acute medical detox (after the initial withdrawal syndrome has passed) then relies on the person continuing in an addiction treatment program.


Resources

  1. https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction
  2. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
  3. https://www.asahq.org/whensecondscount/pain-management/opioid-treatment/opioid-abuse/
  4. https://archives.drugabuse.gov/testimonies/2014/prescription-opioid-heroin-abuse
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2994593/
  6. https://www.ncbi.nlm.nih.gov/books/NBK64236/#A72363
  7. https://naabt.org/faqs.cfm
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874241/