Opioid Use Disorder is a Tenacious Disease
by Richard Ries, MD
Knowing when and if to taper and stop buprenorphine are critical challenges in treating opioid use disorder (OUD). A 19-year-old woman with OUD (IV heroin), a history of depression and self-harm presented to Harborview Medical Center's Addiction Services in Seattle Washington. She was on an SSRI and lamotrigine, was homeless, had recently arrived from across the country, and was quite ill.
Seeing that she was in withdrawal, I took a very brief history then prescribed 8 mg of Suboxone, maintained her other medications, and enrolled her in our clinic's Buprenorphine Treatment Track addiction program, which she attended two times a week. She also began seeing a counselor. She stabilized, but had continued issues of housing, relationships and her Borderline personality. Both her counselor and I utilized 12-step facilitation, even though she was originally quite resistant, and two years later she was in college, with a stable mood and relationship, regularly attending Narcotics Anonymous, and wanted off buprenorphine. Because she had made so much progress and had lab tested and reported sobriety of almost two years, I supported her request. The tapering process was gradual over four months, and following the completion of the taper, she appeared to be stable.
About two months later, she came to the clinic and said, "Dr. Ries, I died last night. The ambulance guys said I was dead for almost a minute. I relapsed to Heroin for two days and I took too much. I think I better go back on Suboxone."
I immediately re-prescribed 8 mg of buprenorphine, relinked her with our group, made sure she was still active in NA, and over time analyzed her relapse and how that occurred. That was all 4 years ago. I just saw this patient this week, and she brought her healthy smiling two year old girl to session, as she always does now. The patient and her husband are both on buprenorphine at stable 8 mg doses, and there has been no drug or alcohol use in either for four years. She finished college with a 3.9 grade point in mathematics and now works regularly in child care for underprivileged kids.
What I have learned from this and other stories, is that opioid addiction is tenacious, and even though a patient is doing everything right, and stabilized in most or all sectors of their life, opioid addiction can come back out of seemingly nowhere--and come back in a lethal manner.