What is Suboxone?
Suboxone is a medication-assisted treatment for opioid addiction*. It is a combination of two medications – buprenorphine, a partial opioid agonist, and naloxone, an opioid antagonist. Opioids, unlike opiates such as heroin, are synthetic opiates. Opioid or Opiate Agonists are compounds that stimulate specific receptors in our brains. An Opioid/Opiate Antagonist is a medication that blocks the opiate receptors, therefore blocking the effects of the opiate.
Buprenorphine is a long-acting medication that fills the brain’s opiate receptors for about 24 hours. When buprenorphine is in these receptors, ‘full opioids’ (e.g. morphine, oxycodone, fentanyl, etc) can’t get in. Because of this, partial agonists are generally safer than full agonists such as morphine, fentanyl, heroin, and even Methadone. If a full opioid is taken within 24 hours of Suboxone, the full opioid will not work. Users will not experience a “high” and will not get pain relief (if pain was the reason it was taken). This is because Buprenorphine tricks the brain into thinking that a full opioid like oxycodone or heroin is in the lock, and this suppresses the withdrawal symptoms and cravings associated with that problem opioid.
Buprenorphine also has a “ceiling effect”. This means that taking more Suboxone than prescribed does not result in a full opioid effect. Taking extra Suboxone will not result in a stronger high. This is a distinct advantage over Methadone (a full opioid). The ceiling effect also helps if buprenorphine is taken in an overdose – there is less suppression of breathing than that resulting from a full opioid.
*Buprenorphine is not useful in treating an addiction to crack cocaine, methamphetamine (speed), MDMA (ecstasy), benzodiazepines (valium and others), marijuana or alcohol.
How we use Suboxone?
Unlike Methadone, Suboxone comes in a pill form and is taken “sublingually” (placed under the tongue to dissolve). The buprenorphine component is absorbed quickly into the blood stream under the tongue. The naloxone portion is not absorbed and must either be swallowed or spit out.
Because Suboxone is a partial agonist, administering it to a client who has recently used opiates/opioids will put him into precipitated withdrawal. Precipitated withdrawal is a rapid onset and intense withdrawal caused by taking Suboxone when you have residual opiate drugs in your system. To minimize the chances of this, our physician will ensure you are in a partial opiate withdrawal state and then slowly introduce Suboxone to your system over several hours while in our detox unit. Your dose will be adjusted over this 24 hour period and then you are reassessed a week later in most cases.
There are many ways clients can use Suboxone as part of their therapeutic treatment program. All clients who primarily or regularly use opiates will begin on Suboxone while with us. After detox, clients remain on Suboxone during their stay with us as it better supports them through their treatment plan. When a client leaves our treatment program and we encourage them to continue on Suboxone for at least 1 year. Prior to their departure, we ensure continued a Suboxone prescription for when they return home is arranged. For more information, see “How will I use Suboxone After I Leave Treatment?.
Therapy and counselling are key components to the success of substitution treatment. Buprenorphine prescribed in combination with counselling and other therapies has a much higher success rate than treatment without counselling. Suboxone allows our clients with opioid addictions to regain a normal state of mind so that they may sooner and more actively participate in their treatment.
Why do we use Suboxone at SCHC?
Opioid-replacement therapies such as Suboxone allow us to focus on our clients’ treatment while ensuring they are safe and stable physiologically. Suboxone reduces the likelihood of clients returning to opiate use as it lessens the uncomfortable, sometimes agonizing, effects of withdrawal.
Not all clients are suitable candidates for Suboxone. Our physician’s assessment will establish the need for Suboxone if there is one. Assessments focus on withdrawal history, prior addiction treatment, and rate of return to opioid use. Suboxone is often an effective treatment for clients with chronic opioid use disorders who have also not done well on Methadone maintenance therapy. We can also help clients who are already on Methadone switch to Suboxone while with us.
Medication-assisted treatment for opioid use disorders is much like using medication to treat other chronic illnesses such as heart disease, asthma, or diabetes. Contrary to popular myths, taking medications for opioid addiction is not simply substituting one addictive drug for another.
How will I use Suboxone After I Leave Treatment?
Stopping Suboxone when you return home after addiction treatment may cause the uncomfortable physical symptoms of withdrawal to return. While you are not addicted to Suboxone, you may be physically dependent on it. Remember, addiction involves not only a physical need for the drug, but other factors such as continued use despite experiencing consequences.
When a client is preparing to leave our drug rehab program, we ensure they have a continued Suboxone prescription for when they return home.
Clients may come back to SCHC to taper off Suboxone after using it for a minimum of 1 year. This is a complimentary service included in a client’s original treatment program. Clients may also get assistance tapering off Suboxone from a physician in their home community.
What are the Side Effects of Suboxone? What about Suboxone vs. Methadone?
Typically patients feel no effect except a decreased need for opiates. Euphoria (feeling high), sedation, and/or nausea is possible if too high a dose of Suboxone is taken. Your stable dose is achieved over 24 hours to a few days (compared to a few weeks with Methadone).
Some people experience side effects, but overall Suboxone is well tolerated. The most common side effects include constipation (typical of all opiates), dizziness or drowsiness, and headache. Weight gain, sweating, and sexual side effects are much less common than with Methadone. Suboxone withdrawal symptoms like abdominal cramps, nausea, diarrhea, insomnia, restlessness, irritability, anxiety and muscle or joint pain may be part of the induction phase, but disappear quickly once a client’s dose is stabilized.
Taken as directed, Suboxone is very safe and does not cause long-term damage to organs, even after several years. Some people do get elevations in their liver enzymes, which reverse once the drug is stopped. In most cases, this is not felt to be of any consequence.
A previous concern about Suboxone vs. Methadone was with respect to the treatment of acute pain. It was believed that Suboxone blocked the effect of other opioids. It is now known that increased opioids are required to treat acute pain in patients on any opioid therapy whether it is long-term opioids for chronic pain, Methadone, or Buprenorphine for maintenance. The amount of extra opioids needed to treat pain is about the same regardless of whether you are on Methadone or Suboxone.
What are the Advantages of Suboxone vs. Methadone?
There are many reasons why Suboxone may be the preferred form of therapy. Some include:
- Less stigmatizing than Methadone
- Stabilization or maintenance dose within the first or second day
- A better safety profile (less likely to cause overdose, little to have no effect on heart rhythms)
- Easier to taper off of than Methadone
- Longer acting than Methadone (may not require daily dosing)
- Fewer side effects, such as constipation
What are the Disadvantages of Suboxone vs. Methadone?
- May not fully satisfy cravings or block withdrawal symptoms for those with high tolerances
- May be more costly if not covered by Ontario Drug Benefit Program
- Dose adjustments may be more difficult
- May cause “precipitated withdrawal”
What is Precipitated Withdrawal?
Suboxone is said to have “low intrinsic activity”. What this means is that once the molecule is attached to a receptor site in the brain, it does not activate or light up that receptor as intensely as other opioids do, including Methadone. A popular metaphor for this is a light switch. Methadone is like turning the light on, whereas Suboxone is like a dimmer switch.
Suboxone also has “high affinity”, meaning it is a very sticky molecule. Once attached to the receptor, it does not like to come off. This is one of the reasons it so long acting. So if an individual who takes Suboxone for the first time also has recently taken any other opioid, the Suboxone will be forced to compete with that other opioid for the receptor. Because of its “high affinity”, it often overtakes the other opioid and takes its place on receptor site instead. This alone does not cause precipitated withdrawal.
Combined together, Suboxone’s does not light up the receptor to the same extent as the opioid that was just kicked out by Suboxone. This is what causes the precipitated withdrawal (e.g. a steep or abrupt onset of symptoms).