Treatment with Zubsolv in a Case Study of Opioid Addiction

By Arwen Podesta MD 06/16/16

A newer MAT option available for combating the opioid epidemic.

Treatment with Zubsolv in a Case Study of Opioid Addiction
A new buprenorphine tablet.

Medication-Assisted Treatment for opioid addiction has been proven to save lives over abstinence-based models, but there are issues with each of the available options. Methadone, for example, requires that patients structure their daily schedules around obtaining the medication. The buprenorphine-based Suboxone doesn’t require daily clinic appointments and has become the most popular alternative to methadone, but there are some patients for whom the medication, for various reasons, is less than optimal. Arwen Podesta, MD, describes a case in which her use of the newest buprenorphine-containing medication available to addiction medicine prescribers—Zubsolv—was instrumental in helping a patient with an opioid addiction enter a period of stable recovery…Richard Juman, PsyD

The opioid addiction problem is overwhelming: You cannot watch the news without hearing a story on opioid misuse or a report of another tragic overdose and death.

It has been a problem for a long while, but has escalated to epidemic proportions in the last several years—so much so that legislative bodies and the CDC have gotten involved. Big money is being appropriated for prevention and treatment of addiction, particularly opioid addiction. (Opioids include heroin and also pain medicine like Percocet, OxyContin, Vicodin, fentanyl and more.) With the poor success rates of treatment overall, we have had to change our thinking on treatment. Quitting cold turkey rarely works for long. Behavioral models, like 12-step or abstinence-based therapeutic settings, work for some but not all. Relapse is common and frequent. On average, a person struggling with addiction tries to stop thirteen times before it sticks.

For years, the too few number of addiction medicine doctors has utilized medications to treat the disease. With the current trend and a national eye on addiction, more professionals are specializing in this type of care, called Medication-Assisted Treatment (MAT). MAT embraces behavioral therapy in conjunction with medicines for cravings, relapse prevention and overdose prevention. Medicines that fall into this category include naltrexone (an opioid blocker taken daily or monthly), naloxone (an opioid blocker used for overdose rescue), methadone (an opioid agonist), and buprenorphine (an opioid partial agonist). I have seen patients undergo phenomenal transformations using MAT plus behavioral therapy and lifestyle change. Choosing the right medicine for patients’ needs is both an art and science. I use Vivitrol (naltrexone monthly injection) for some, buprenorphine in various forms for others, and other medicines for cravings, anxiety, mood and sleep. I also use nutrition and appropriate vitamins and supplements to help patients feel better through their recovery. 

For many years, the only brand of medicine containing buprenorphine was Suboxone. I have been prescribing Suboxone (a combination of buprenorphine and naloxone) since 2010, and find it to be an easy to use and very effective medication. It has become a medicine that is often available on the black market though, on the streets, bought and sold in the same locations as illicit pain pills and heroin. Most people taking Suboxone illicitly are actually taking it to bridge into treatment, or to detox off of pain pills or heroin. 

Last year, a new brand joined the arena of MAT, Zubsolv, giving addiction medicine physicians more flexibility for opioid addicts that need a buprenorphine product. Zubsolv is equal to Suboxone in efficacy but has some added benefits that patients like—notably taste, dissolve time, and price. I also choose it as an option for patients who have used Suboxone from the streets. 

I have been working with a patient for a while where this was the case. 

“Doug” is a 45-year-old lawyer with a strong family history of addiction. He has often been depressed and isolative, feeling uncomfortable around people. In college, he dabbled in drugs and alcohol. He found that alcohol eased him socially, and that opioid pain pills gave him energy. His intellect, fortitude and academic drive were strong enough to talk himself out of using drugs regularly, and he avoided addiction at that time, despite his genetic leanings toward addiction.

After law school and passing the bar exam, Doug began a career at a high-pressure firm. His days were long, he worked most weekends, and his boss was tough on him. He began to have a few drinks nightly to ease his stress and help him sleep. One evening he had a minor fall on the sidewalk, resulting in some scrapes and cuts. He brought himself into urgent care where they cleaned up his injuries and also gave him some pain medication, the opioid pain medication OxyContin. The prescription was for just a few weeks. 

Doug took the medication as prescribed. More than healing the pain, he found the pills helped him focus and stay “on” during his long arduous hours at work. He no longer needed the nightly cocktails to take the edge off. Once he ran out of the medication, he found he had less energy and less ability to cope with his stressful job. And his sleep was also more difficult, so he started drinking in the evening again. 

Doug went to his primary care doctor and mentioned that he still had pain from the fall. That doctor did not write any prescriptions, but gave him a referral to pain management. He started seeing a pain management doctor, who began writing prescriptions for OxyContin twice daily, for months at a time. A few months in, Doug developed tolerance and started taking more than prescribed. The first time he ran out early, he felt horrible, thought he had the flu, and took a few days off of work. Once he restarted the pain meds, he felt normal again. He realized that he had not had the flu but had been in opioid withdrawal. The medicine, or lack thereof, was affecting his work and his well-being.

This is when Doug first came to see me. He initially came into my practice seeking therapy from an addiction counselor who works in my office. The day of his first therapy appointment, Doug was sick without the pain pills. The therapist wanted to get him stable without sending him to the hospital, so he met with me for a medication evaluation. I prescribed Suboxone, and he stabilized quickly. He found that the right dose of Suboxone was more effective than the pain pills for that “on” feeling, energy, focus and even sleep—and without getting high. He and the therapist started working on life balance and mental wellness.

A few months later, Doug’s brother lost his apartment and Doug allowed him to move in. Unbeknownst to Doug, his brother was actively using pills; he was buying pain pills from the street and injecting at Doug’s house. Within a month Doug found out, but he was not worried about his own recovery or risk of relapse because he was on the right medication and in good treatment. One day though, the brother found the Suboxone and took Doug’s last week’s worth all at once. Luckily, this medication has a safety net, so the brother did not overdose. 

Doug came home to find his medications gone. His brother admitted to taking them, and offered pain pills to replace the Suboxone. Doug refused for a few days, but found his cravings too strong. After three days he caved and reluctantly accepted the pain pills. His brother was a major stressor, but also part of the solution, or really the temporary fix. Doug relapsed hard. He began using pain pills from the street, taking higher doses. He began injecting.

Doug’s job did not tolerate his inconsistencies and absences, so he was given three months leave. During this time, he continued to use pain pills, and also started buying Suboxone from the street. He and his brother shared both, and they would “eat pieces” of the Suboxone to tide them over until the next fix.

Doug missed his appointments with me and with his therapist. We reached out and left messages, but were unsuccessful in getting him back into treatment. Finally, after four months, Doug came to our office, met with me and the therapist, and we made a new plan. 

The plan included some major changes. For medications, Suboxone was no longer on the table, as the flavor and style of taking had become ritually associated with street use and pill addiction. I decided to use the new Zubsolv, which had recently become available, instead. We started this medication at a comparable dose to the Suboxone. Since the flavor and packaging are different, he had no association or memory of street use. We also insisted that he and his brother live separately. Doug moved in with an uncle for a month, while his brother sorted out his own circumstances, going to a detox facility then residential rehab. 

It has been over a year and a half since Doug started taking Zubsolv, and the outcome has been fantastic, as Doug has remained stable and well for over 18 months, the longest time since he began using opioids.

With MAT and therapeutic and psychosocial changes, Doug has been doing phenomenally well. He has been successful at work, has had no cravings, and has even started dating someone seriously. We know that addiction is a relapsing disease, but with every year of success, the likelihood for another year increases. We may use Zubsolv for a long time, or maybe taper him off and use something like Vivitrol. We will continue to reevaluate and discuss, using what is best for him. He, like all who suffer from addiction, still has this disease, but he is in great treatment and recovery. This is my goal for all patients. Using the best tools we have, we can reach that goal. 

Arwen Podesta, MD, is a psychiatrist with sub-specializations in addiction medicine, forensic psychiatry, and integrative & holistic medicine. She is clinical faculty at Tulane School of Medicine, is medical director at Odyssey House, works at ACER IOP, consults for Orleans Criminal Court Intervention (Drug Court), and has a private practice in New Orleans. Dr. Podesta is also a well-known speaker who travels to teach and speak on the subjects of Addiction Medicine and Integrative Psychiatry.

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