Nearly two million Americans are addicted to painkillers such as oxycodone (OxyContin), hydrocodone (Vicodin), and meperidine (Demerol). Painkiller addiction has soared since the early 1990s — to the point where it now dwarfs cocaine and heroin addiction. Now a large randomized controlled trial suggests that painkiller addiction may be similar to heroin addiction in one important way — that it requires ongoing treatment with a substitute drug to quell cravings.
Researchers at McLean Hospital led the national study, which involved 653 people addicted to painkillers. Half of the participants were randomly assigned to standard medical management (occasional clinician visits and referrals to self-help groups) while the other half received more intensive outpatient drug counseling. In addition, all participants received Suboxone, a pill that combines buprenorphine with naloxone. Buprenorphine relieves withdrawal symptoms while delivering less of a “high.” But some people abuse buprenorphine — which is why the narcotic-blocker naloxone was added. When the patient takes Suboxone under the tongue as directed, very little naloxone is digested and absorbed into the bloodstream. But if the patient crushes the pill for injection, intending to abuse the drug, naloxone floods the bloodstream, neutralizing the slight “high” from buprenorphine while causing unpleasant side effects.
During the first phase of the trial, participants took Suboxone for only two weeks, followed by a two-week taper (a gradual discontinuation of the medication) and eight weeks of follow-up. By the end of this initial “brief treatment” phase, only 7% of participants were able to kick the painkiller habit — the others had relapsed.
During a second phase of the trial, 360 participants who had relapsed underwent a more extended treatment protocol that consisted of taking Suboxone for 12 weeks, followed by a four-week taper, and eight weeks of follow-up clinical visits. This time the results were — at least initially — more encouraging: 49% had overcome the painkiller addiction after 12 weeks on Suboxone. However, most relapsed after they stopped taking the drug. By the time the study ended, only 9% remained free of the painkiller addiction.
Thus the study suggests that painkiller addiction may require ongoing treatment with another medication (such as methadone for heroin) to blunt cravings and help people maintain recovery. An open question, however, is how long this substitute drug treatment needs to extend.
Weiss RD, et al. “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry (Nov. 7, 2011): electronic publication ahead of print.