Suboxone Addiction

Article Overview

• Suboxone is a brand-name combination of the opioid buprenorphine and the opioid-blocker naloxone
• Suboxone is only used for treating opioid dependence
• Buprenorphine – the opioid in Suboxone – has inherent pharmacological properties that make it especially well-suited to treating opioid dependence
• Suboxone is often diverted and misused

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Is Suboxone Addictive?

Suboxone contains an opioid and therefore it is possible to get addictive. However, it is only a partial opioid agonist, so people who are tolerant due to regular opioid use usually feel no high, and those who are opioid-naïve don’t feel much of a high compared with other opioids.

A study in the U.S. showed that getting high is not the major motivation for using diverted Suboxone; rather, it is most often used to self-treat withdrawal symptoms.

Suboxone addiction symptoms may include:

• Using Suboxone that was not prescribed to the individual using it, or at doses above what were prescribed
• Using Suboxone for reasons other than its intended use
• Using Suboxone to support other drug use
• Injecting Suboxone
• Obsessive thoughts about using the drug
• Drug-seeking behavior: lying or otherwise using illegal means to obtain the drug
• Avoidance and loss of interest in normal daily/life activities and responsibilities due to Suboxone use
• Lying and other deceitful behaviors to cover up the drug use
• Irrational beliefs in order to support and rationalize the drug use
• Using the drug to cope with negative feelings and emotions or to cope with life

Suboxone withdrawal is also possible. When a patient uses Suboxone, their doctor will often have them taper down their dosage gradually over time to reduce withdrawal symptoms.

Understanding Suboxone

The opioid addiction and overdose problem is a national crisis, but Ohio has been especially hard-hit by this deadly epidemic. According to the U.S. National Institute on Drug Abuse, in 2017 Ohio had the second highest rate of drug overdose deaths in the U.S., with 39.2 deaths per 100,000 persons. This is more than double the national average of 14.6 overdose death per 100,000 population.

Fortunately, for people who are addicted to opioids, there is help available. Some individuals may wish to include opioid replacement therapy as part of their addiction treatment to help them navigate the tough journey of withdrawal and reduce cravings while they heal. The medication Suboxone provides an attractive option for such treatment.

What Is Suboxone?

Suboxone is a brand-name drug used for opioid-replacement therapy in the treatment of opioid dependence, most often in the setting of opioid use disorder (OUD). It contains the opioid buprenorphine and the opioid-blocker naloxone (Narcan) in a 4:1 ratio.

Buprenorphine is a unique synthetic opioid that has specific pharmacological properties that make it especially useful for treating OUD. Some of these qualities include:

• Long-acting: buprenorphine has a long half-life compared to other opioids (31–35 hours), so it doesn’t wear off quickly. This helps prevent withdrawal and cravings. As well, because of its long half-life it can be dosed every other day or twice weekly, making it easy to use for office-based care.
• High-affinity for opioid receptors: it attaches strongly to opioid receptors in the brain, stabilizing them and pushing other opioids out of the way. This reverses the effects of other opioids in the individual’s system and blocks other opioids if the individual tries to relapse. This helps prevent abuse of Suboxone or other opioids
• Partial opioid agonist: it has very little opioid activity, so it causes very little “high” (people who have been using opioids regularly generally don’t feel any high at all) and has a lower overdose risk compared to other opioids
• Ceiling effect: its negative effects max out and don’t increase with further use, making overdose much less unlikely

Naloxone — the other active ingredient in Suboxone — is an opioid blocker ( a so-called “opioid antagonist”). It is used on its own to save lives when people have overdosed on opioids. When it is mixed with buprenorphine — as it is in Suboxone — it helps to prevent attempts at abusing buprenorphine or other opioids by blocking their effects.

Suboxone is more expensive than methadone — the other opioid that is approved for treating – but it has a better side effect profile and is six times less likely to cause an overdose compared to methadone. As well, Suboxone can be administered from a physician’s office, unlike methadone, which must be dispensed via specially licenced methadone clinics that may have long waiting lists and other barriers to access.

Suboxone has been shown by research to be as good as methadone, better than naloxone therapy alone, and better than abstinence-only for treatment retention and maintenance of recovery in the short term. Suboxone has less abuse potential than methadone and can be tapered off more quickly.

Classification

Is Suboxone an opiate? The short answer is no; however, it is classified as an opioid. The difference is that an opiate is a chemical that occurs naturally in the opium poppy (such as codeine or morphine), whereas and opioid is either a semi-synthetic derivative made by chemically altering an opiate (such as hydrocodone or heroin) or a fully synthetic manufactured version of an opiate (such as fentanyl or buprenorphine).

As such, the Suboxone drug class may be described as a combination drug of the synthetic partial opioid agonist buprenorphine and the opioid antagonist (naloxone).

What Is Suboxone Used For?

Suboxone has only one FDA-approved use in the U.S.: the maintenance treatment of OUD. Suboxone is not approved for treatment induction, or initiating treatment. It is used for maintenance therapy in individuals who have been inducted using the buprenorphine-only medication Subutex.

Suboxone is therefore used to reduce or eliminate withdrawal symptoms in people who have regularly used opioids while they detoxify from the drugs, and to reduce opioid cravings in early recovery. Unlike some buprenorphine-containing drugs, Suboxone is not intended for pain management.

Suboxone is different from methadone, which is also a medication-assisted treatment for opioid dependence. Methadone is only administered at special clinics, while a doctor can prescribe suboxone. Suboxone can be used at the start of someone’s treatment journey and it can also be used in recovery.

Suboxone is primarily used to help treat dependence on short-acting opioids including prescription pain medicines and heroin rather than longer-acting opioids.

Medication-Assisted Treatment

Suboxone is not intended to be a stand-alone treatment for OUD; rather it is meant to be a part of medication-assisted treatment (MAT), which combines medications and counseling and other addiction treatment measures.

Suboxone should be regarded simply as a way of reducing withdrawal symptoms and cravings so as to allow individuals to focus on receiving proper addiction treatment. Suboxone helps people stop using opioids, but recovery is not simply the absence of using drugs.  Treatment is the process that identifies and addresses the causes behind the drug use and the mental and physical effects of the drug use. This allows for healing to take place and provides the very best opportunity for long-term recovery and a return to good health.

Dosage and Administration

Suboxone comes as a sublingual (dissolved under the tongue) tablet or film strip. The Suboxone dosage is the same using either form of the drug.

Suboxone dosage is titrated to effect, starting with a low dose (2–4 mg) and increasing in increments of 2–4mg of buprenorphine to a level that adequately suppresses withdrawal symptoms.

The maintenance dose is usually in the range of 4–24mg of buprenorphine per day; the recommended target dose is 16mg of buprenorphine per day. Due to the ceiling effect of buprenorphine, doses above 24mg per day are unlikely to have an added benefit.

Suboxone administration is by dissolving the tablets or film under the tongue. Buprenorphine is not absorbed into the body if it is swallowed. Individuals should not eat or drink until the drug is completely dissolved.

Prescribed Methods

Suboxone and buprenorphine-only Subutex are the only opioid replacement therapy drugs that are cleared for use outside of narcotic treatment programs. As such, doctors can apply for a licence to prescribe Suboxone (for up to 100 patients per doctor) directly from their office.

This has greatly increased the availability of Suboxone for the people who need it. In 2012 9.1 million prescriptions for Suboxone were issued in the U.S., by 2017 this had increased to 14.6 million.

Abusive Methods

Studies have shown that 18–28% of people who participate in outpatient opioid-replacement therapy programs (with buprenorphine or methadone) have diverted their prescribed drug either by sharing or selling it.

Buprenorphine is, by far, the most abused prescription opioid in America. The abuse rate of Suboxone is much lower than that of buprenorphine-only formulations (such as Subutex), but it still occurs.

One study found that 74% of people who use diverted Suboxone do so to self-treat opioid withdrawal, mostly because they cannot afford to obtain it by prescription. Some individuals manage their opioid dependency by keeping their Suboxone on hand to manage withdrawal symptoms when they do not have their drug of choice, a rather dysfunctional arrangement.

The most concerning form of abuse of Suboxone is by using it by intravenous (IV) injection. Besides the usual risks of IV drug use (infection, embolism etc.), IV use of Suboxone carries a significant risk of overdose. About 16.3% of people receiving prescriptions for a buprenorphine-naloxone combination drug (such as Suboxone) report having used it IV in the past month.

What Does Suboxone Look Like?

Suboxone sublingual tablets come in two different strengths (2 and 8mg buprenorphine) and both are six-sided and orange.

Suboxone strips come in four different strengths (2, 4, 8 and 12mg buprenorphine) but all are small rectangular orange patches.

Generic Names

In June 2018 the FDA approved two generic forms of the Suboxone sublingual film (from Mylan, Alvogen Pine Brook and Dr. Reddy’s laboratories). The Suboxone generic name is simply buprenorphine-naloxone. No generic forms of the Suboxone sublingual tablets are available to the public.

Other Names & Street Names for Suboxone

Given the widespread use and abuse of Suboxone, it is not surprising that the drug has acquired a certain notoriety among people who abuse opioids. According to a DEA report, Suboxone alternative names (i.e., street names) are:

• Boxes
• Bupes
• Oranges
• Sobos
• Stop Signs
• Subs

Side Effects of Suboxone

Some of the common Suboxone side effects include:

• Dependence or addiction
• Headache
• Low energy, lethargy and fatigue
• Sweating
• Constipation
• Drowsiness
• Confusion, impaired cognition (thinking, planning, calculating, etc.)
• Low blood pressure
• Withdrawal symptoms
• Overdose

Because of Suboxone’s sedating and cognitive effects people should not operate machinery or drive until they see how Suboxone affects them.

Another side effect of Suboxone is precipitated withdrawal. Both active ingredients of Suboxone will displace other opioids from their receptors in the brain. As such, Suboxone-precipitated withdrawal may occur if the drug is started too early after the last use of opioids. This is why Suboxone is not used for treatment induction.

How Long Does Suboxone Stay in Your System?

Buprenorphine — the ingredient in Suboxone that relieves withdrawal symptoms — takes three to four hours to reach peak levels in the blood and to have its maximal effect.

How long does Suboxone last? Suboxone’s half-life is mainly determined by the half-life of buprenorphine; the two active ingredients in Suboxone have different half-lives:

• Buprenorphine: 16.4 to 27.5 hours
• Naloxone: 1.9 to 2.4 hours

Buprenorphine is a much stronger binder to opioid receptors than naloxone and stays active in the body much longer, so it determines how long Suboxone’s duration of action lasts. It generally takes three to five days from the last dose until buprenorphine levels drop low enough to start causing withdrawal symptoms.

Success Rate of Suboxone Treatment

Long-term Suboxone treatment reduced setback death rates in half when used as part of long-term recovery. One study conducted by the National Institute on Drug Abuse (NIDA) looked at 600 outpatients who sought treatment for prescription opioids. Of those, 49 percent of participants reduced prescription painkiller abuse during extended Suboxone treatment. “Extended” referred to a period of at least 12 weeks.

However, that success rate went down to 8.6 percent when participants stopped using Suboxone. Other reports have put the success rates of Suboxone treatment as high as 40 to 60 percent based on recovery program retention rates.