Sometimes patients come in to the doctor to request a short term detox treatment to help quit heroin or other opioids using medication assisted treatment. They are very specific in asking for a detox plan that will be completed in a week or two. These patients do not want to be on Subutex, Suboxone or ZubSolv for many months or even years. The proven method of preventing relapse is to maintain the patient on medication for longer time periods. Psychiatric News supports this with research that medication maintenance works best. How should doctors handle such requests for short term, fast tapering?
Often, the underlying reason behind a patient proposing such a plan is that it follows the standard of many detox programs. Patients who have already been through the abstinence based addiction treatment system are familiar with a 1-2 week detox using Subutex. They are told that buprenorphine, the active ingredient in Subutex, Suboxone and ZubSolv, is only safe for very short term use.
This is a philosophical difference in detox treatment methods between abstinence based programs and medication maintenance programs. The evidence supports a higher rate of success with maintenance treatment. Should doctors refuse to work with these patients who insist on short term, fast tapering?
Some doctors may see this situation as a moral dilemma. They want to provide the best evidence based care for the patient. What if the patient relapses? Relapses with heroin have a high incidence of overdose death. Fast tapering off of medication seems too risky.
Of course, the doctor should discuss the benefits of maintenance treatment even if the patient is insistent on following the short-term plan. It is important that doctors inform patients of their choices and make the best recommendation based on current evidence based medicine.
It is true that there are many examples of success stories without maintenance treatment. A patient was given Subutex for a short time or did not get any detox medication and stayed clean. These stories can be heard in the meetings of recovery.
Unfortunately, the statistics show that the successes are more the exception than the rule. Should doctors refuse to taper patients quickly? Should they send patients away who insist on very short term treatment?
The doctor must discuss in detail what is involved in a good program of recovery. They may discuss the importance of daily meeting attendance, sponsorship and developing a network of support within the recovery community. And, it should be made clear that the better and safer path is to remain in treatment with maintenance medication on a monthly basis. The patient should also be informed that if there is a relapse event, the patient is welcome to return to resume treatment.
