Suboxone is the brand name of a prescription medication designed to help people with opioid addiction taper off their physical dependence on the drug. This combination of buprenorphine and naloxone was created as a way to reduce the potential to abuse buprenorphine, which is a partial opioid agonist.
As Suboxone became more widely prescribed to those trying to stop abusing other opioid drugs, like heroin or codeine, Suboxone itself became a substance of abuse. There are about 15,700 physicians who can prescribe buprenorphine and buprenorphine-naloxone combination products, like Suboxone, in the United States. There were about 3.5 million prescriptions for these products in 2008.
What is Suboxone?
Suboxone is a combination of two existing drugs: buprenorphine and naloxone. Buprenorphine is a partial opioid agonist that binds to the brain’s opioid receptors for a long time while naloxone kicks any opioid off those receptors and takes its place for a short period. How do they work together?
Buprenorphine has been used as a medication-assisted treatment (MAT) in Europe for decades, but it was only approved in the United States for this purpose in 2002. Methadone has been the preferred method of tapering off heroin abuse for decades in the U.S., but that drug is a full opioid agonist, and though it worked for many people who needed long-term tapering, it also was a drug of abuse.
Additionally, methadone can only be dispensed through specific clinics with addiction specialists who are specifically trained to administer this drug, so it is not convenient for many people who may struggle with mild or moderate opioid addiction. Buprenorphine can be dispensed for outpatient treatment from physicians’ offices, as long as the physician has additional training in this approach to detoxing from opioid abuse.
Buprenorphine can lead to a high for people who are opioid-naïve, and many people who have received buprenorphine prescriptions to taper off opioid dependence have found ways to increase the bioavailability of the drug, so it feels like heroin or another opiate. These ways included drinking alcohol or taking benzodiazepines along with buprenorphine because these drugs are known to increase the feeling of being high; taking buprenorphine with another opioid drug to compound the effects; or snorting crushed tablets, injecting liquified film strips, or simply taking a lot of buprenorphine at once.
To combat the risks of buprenorphine abuse, Indivior, the pharmaceutical company behind Suboxone, combined buprenorphine with naloxone to prevent abuse. When someone prescribed Suboxone took it as directed, buprenorphine would be absorbed through the digestive system and make its way to the brain, where it would bind to the opioid receptors for a long time, easing withdrawal symptoms but not causing a high. If the drug is abused, however, naloxone becomes active instead, preventing any opioids from binding to the receptor cells, which will cause an intense withdrawal experience.
When used by itself, naloxone temporarily reverses an opioid overdose. Although naloxone is metabolized out of the body much faster than other opioids, the drug can give someone experiencing a potentially fatal opioid overdose a chance to get the emergency medical attention they need.
Naloxone is an opioid antagonist that quickly restores normal respiration. Depressed, shallow, and stopped breathing are the leading causes of death during an opioid overdose. Legislation throughout the U.S. is pushing to make injectable and nasal spray versions of naloxone easy to obtain without a prescription through a pharmacist or other medical professional.
The pharmaceutical company that created Suboxone intended for naloxone to block potential forms of compulsive drug-taking in people who have relapsed into opioid abuse during treatment. However, there have been many reports of people abusing Suboxone as the substance becomes more widely available. Suboxone was so well-regarded as a low-risk drug when it came out that it was one of the first two drugs, per the Drug Abuse Treatment Act of 2000, that was believed to help with the increasing shortage of addiction treatment centers.
Suboxone Abuse vs. Medical Use
Although access to Suboxone is important, it should only be taken with consistent medical supervision. Before states began adopting prescription monitoring programs, many people who struggled with opioid addiction—including to Suboxone after it began to be dispensed—had a habit called doctor shopping. This habit involves going to multiple doctors, reporting similar symptoms, and receiving prescriptions for multiple opioids, including buprenorphine drugs. As prescription monitoring systems began to reduce doctor shopping, some people crossed state lines to get to doctors who would prescribe drugs for them. Several Suboxone clinics were, according to some investigative journalists, cash only to prevent Suboxone patients from being traced by their insurance or state.
People taking Suboxone must follow their physician’s orders to the letter; otherwise, they risk slipping back into drug abuse. It may be difficult for people who suffer from unemployment or unstable job prospects because of their addiction to cover the cost of inpatient detox, which would oversee their Suboxone prescription and reduce their risk of relapse. Without needed social support and oversight, too many people return to substance abuse patterns during detox and rehabilitation.
Suboxone has been stolen through doctor shopping and diverted for abuse among people who are opioid-naïve. The dose of buprenorphine contained in a Suboxone tablet or sublingual filmstrip is intended for someone who has abused opioid drugs and developed a tolerance to them. In someone who has not abused other opiates, Suboxone can cause intoxication.
Suboxone works well in the right setting. A 2014 study involving opioid addicts found that 31.7 percent of participants remained abstinent after 42 months (3.5 years) and no longer needed MAT; 29.4 percent were opioid-abstinent but remained on a slow MAT taper. According to the FDA, Suboxone treatment requires the following monitoring protocol:
- Regular physician visits, spaced at intervals based on how physically and mentally stable the patient is
- Assessing and reinforcing the patient’s compliance with the prescription medication
- Making sure the Suboxone dose is the right amount
- Assessing if the patient is receiving appropriate psychosocial support from friends, family, therapy, and rehabilitation
- Determining if the patient is making appropriate or adequate progress toward their goal of overcoming addiction
Most people who work with their physician through the monitoring process above will safely detox from opioid addiction. In other cases, some people may fall out of the program, not receive good monitoring to begin with, or partake in other kinds of drug abuse that make buprenorphine more intoxicating.
Even when taken as prescribed, Suboxone may cause side effects; however, like other kinds of prescription drug abuse, side effects are more likely to appear and worsen in people who abuse these drugs for nonmedical reasons.
Common Suboxone Side Effects Include:
- Stomach pain
- Nausea and vomiting
- Trouble falling or staying asleep
- Blurred vision
- Tongue pain
- Numbness or redness in the mouth (sublingual strips)
- Back pain
More Serious Side Effects of Suboxone Exist, Such As:
- Hives, itching, or skin rashes
- Trouble breathing or slowed breathing
- Trouble swallowing
- Stomach discomfort
- Strange bleeding or bruising
- Severe fatigue
- Lack of appetite
- Reduced energy
- Flulike symptoms
- Yellowing of the skin or the whites of the eyes (jaundice)
- Pain in the upper right area of the stomach
Like any opioid agonist or partial agonist, it is possible to overdose on buprenorphine. Naloxone has no reported side effects, so it is not considered dangerous; however, buprenorphine has a profound effect on the brain and body, so too much of this drug can lead to an overdose. Misusing Suboxone to bypass naloxone greatly increases the risk of overdose.
If someone displays any opioid overdose symptoms, call 911 immediately. They need emergency medical attention, even if you have naloxone available to reverse the overdose. Naloxone will leave the body faster than opioids will, especially long-acting drugs like buprenorphine.
Symptoms of Being Overmedicated on Buprenorphine or Another Opioid, Which Precede an Overdose Include:
- Unusual sleepiness or drowsiness
- Trouble staying awake or focusing on surroundings
- Mental confusion
- Slurred speech
- Loss of physical control
- Slow or shallow breathing
- Pinpoint pupils
- Slow heartbeat and low blood pressure
Once an Opioid Overdose Takes Hold, Certain Signs are Apparent. Some of Them Are:
- A pale face or skin that is clammy to the touch
- Limp body and muscles
- Bluish fingernails or skin from oxygen deprivation
- Vomiting or making gurgling noises
- Passing out and cannot be roused
- Reduced or stopped breathing and heart rate
- Pinpoint pupils
Suboxone should only be used to manage withdrawal symptoms as a form of MAT to ease the body off dependence on other opioid drugs, like heroin or OxyContin. However, suddenly quitting buprenorphine drugs—whether they are being taken as prescribed for a taper or because the substance is being abused recreationally—can cause withdrawal symptoms. These symptoms will last longer than other opioid withdrawal symptoms because buprenorphine remains in the body for longer than substances like codeine, heroin, or hydrocodone. Symptoms include:
- Muscle aches
- Watery eyes
- A runny nose
- Excessive sweating
- Trouble sleeping
- Yawning too much
- Abdominal cramps
- Nausea or vomiting
- Dilated pupils
- Blurry vision
- Feeling like you have the flu
- Rapid heartbeat
- High blood pressure
Buprenorphine’s half-life is about 37 hours, so it may take between one and three days for the drug to completely metabolize out of the body and for withdrawal symptoms to begin. During this time, It is important to work with a medical professional to monitor withdrawal symptoms from such a long-acting drug. They may begin suddenly and unexpectedly, which could trigger compulsive behaviors to relapse back into opioid abuse.
“Although opioid withdrawal has very few life-threatening risks, it is uncomfortable and difficult to complete on one’s own. The only way to ensure safe and successful detox is to work with addiction specialists to manage a taper. ”
Naloxone has no withdrawal symptoms because the body cannot become dependent on it.
Treatment for Suboxone Abuse
MAT is a crucial part of opioid addiction treatment; however, abuse of opioids is complicated when one of the MAT drugs is the substance of abuse. Start with an evaluation from an addiction specialist who can refer you to an appropriate detox program. If you have abused opioids for a long time and have a high tolerance, you may still work with someone who can taper your dose of Suboxone; if you have not abused a large dose of buprenorphine for a long time, your physician may use other medications, like anti-nausea drugs and nonsteroidal anti-inflammatory drugs (NSAIDs), to manage withdrawal symptoms.
Detox is very important, but it is only the first step in addiction treatment. The next step, which is equally important, is rehabilitation. The core of rehabilitation programs is behavioral group therapy, but many intensive outpatient and inpatient, or residential programs offer individual therapy and complementary therapies as well. These approaches can help you tailor your mental and emotional needs to get the best social support as you learn better coping mechanisms.
Once you have completed detox and rehabilitation, your counselor or addiction specialist should work with you to develop an aftercare plan. These will be very individual plans that are designed to help you transition into a healthy, sober life.