When stopping buprenorphine therapy, taper the medication gradually to minimize withdrawal discomfort and relapse risk. Start tapering by 2 mg per month, then taper more rapidly or slowly based on the patient’s subjective experience.
TREATMENT: An opioid option
After discussing the risks and benefits with Mr. B and his wife, we add buprenorphine/naloxone, 8 mg/d, then increase it to 16 mg/d the next day. He tolerates the medication, and within 1 week his anergia disappears and he feels more motivated and productive. He reports no euphoria from buprenorphine but says it decreases his craving for alcohol, benzodiazepines, and opioids.
We continue buprenorphine/naloxone, 16 mg/d, and mirtazapine, 30 mg at bedtime, and reduce venlafaxine to 225 mg/d to mitigate sexual side effects. During weekly individual psychotherapy, we target Mr. B’s marital conflict and low self-esteem, and instruct him on overcoming life obstacles such as unemployment. He is looking for work and attends AA approximately 5 times a week.
Treating comorbid depression and substance abuse?
Remember these 8 steps
Remember these 8 steps
- Address depression and substance abuse concurrently
- Communicate regularly with other providers about progress on depression and substance abuse issues
- Recommend and support involvement in 12-step programs such as AA
- Use medications for both depression—such as antidepressants—and relapse prevention—such as naltrexone, acamprosate, or buprenorphine/naloxone
- Explore family history of addiction and how this affected the patient developmentally. Find out if depression and substance abuse had common causes; this helps the patient realize that he/she did not become depressed or addicted by choice
- Ask about and discuss multiple addictions that were not initially reported
- Help the patient express, tolerate, and experience difficult feelings rather than avoid them
- Empathize with the patient; express understanding that factors out of the patient’s control caused depression and addiction
The authors’ observations
Considering the tumultuousness of Mr. B’s life, his willingness to enter psychotherapy and address underlying issues is significant. Adding buprenorphine to his antidepressant regimen helped stabilize his mood and make psychotherapy possible.
Psychotropics have not induced total remission of Mr. B’s depression, which is multifactorial and requires multimodal treatment. Still, we consider buprenorphine therapy at least partially successful—he has gone 6 months without attempting suicide or requiring psychiatric hospitalization.
Some clinicians consider buprenorphine’s potential for physical dependence a drawback to depression therapy. Physical dependence on a psychotropic does not necessarily outweigh its benefit in severe depression. Indeed, patients with depression can experience discontinuation symptoms from selective serotonin reuptake inhibitors and withdrawal from benzodiazepines.2,12
FOLLOW-UP: ‘Bup’ stigma
Mr. B feels stigmatized about buprenorphine use, partly because his wife shames him for his history of addiction and views buprenorphine as a constant reminder of his “failures.”
Mrs. B’s dysfunctional attitude leaves Mr. B too ashamed to tell his fellow AA members that he takes buprenorphine. His inability to share these feelings also diminishes his sense of belonging in the 12-step fellowship. Even so, he feels that buprenorphine has helped him tremendously and wants to continue taking it.
During psychotherapy, we address Mr. B’s buprenorphine-related stigma and pervasive shame stemming from his history of mental illness, addiction, inability to work in his chosen field, and past employment failures. We encourage him to overcome his shame by pointing out his strengths—such as the skills he can offer potential employers—and by emphasizing that he did not choose to become depressed and addicted.
The authors’ observations
Most patients addicted to opiates feel much less stigmatized by buprenorphine therapy than by methadone. Patients who feel shame while taking buprenorphine usually are reacting to past opioid addiction rather than current therapy. Mr. B’s buprenorphine-related shame stems from his personality structure.
Shame, however, could create negative expectations of buprenorphine therapy, and can lower some patients’ self-esteem to the point that they feel they do not deserve to get better. Some patients stop buprenorphine prematurely because they believe they have beaten the addiction, but this often leads to relapse to the previous opioid of choice.
Help patients work through the shame of past addiction and encourage them to view buprenorphine therapy as a positive step toward recovery (Box 2). As mental health professionals, we must not collude with society to shame people with past chemical addiction. Creatively yet responsibly broadening our perspective toward psychiatric intervention can help patients such as Mr. B receive optimal treatment.