For most of the last century, the ability of doctors and treatment centers to help opioid addicts has been limited by the federal government. The Harrison Narcotic Act of 1914, originally designed as a tax act, was interpreted by the Supreme Court to prohibit the prescription of opioids to opioid addicts, even in the course of their treatment. From then on, an entire line of practice – the tapering of opioid dosage to ease the pain of withdrawal – was against the law.
One exception was methadone. When used properly, methadone maintenance is an effective treatment for opioid addiction: it blocks the effects of other opioids like heroin and greatly improves the patient’s psychosocial stability. Unfortunately, hostility to the idea of maintaining addicts on a substitute drug has led to federal restriction of methadone that is so tight that the drug can only be prescribed by specific clinics. These clinics vary widely in the quality of care they provide. Additionally, methadone can cause euphoria, which can increase the probability of relapse. The combination of these factors has limited methadone’s effectiveness as a medication not only for maintenance, but for detoxification as well.
In the latter part of the twentieth century, the medical management of opioid withdrawal was largely left to treatment centers, where physicians could prescribe only a handful of symptomatic medications. Opioid addicts who could not afford medical treatment are left to detoxify themselves “cold turkey,” which usually results in a return to opioid drug use.
Now there is hope on the horizon. The Drug Abuse Treatment Act of 2000 allows the prescription of buprenorphine to opioid addicts to ease the symptoms of withdrawal. Whereas drugs like morphine, heroin and methadone are opioid receptor agonists – meaning they fully bind opioid receptors – buprenorphine is a partial opioid receptor agonist. This gives buprenorphine the ability to relieve the symptoms of opioid withdrawal without producing the euphoria of the full agonist drugs like methadone. For the first time, physicians can use buprenorphine to provide a comfortable detox for opioid addicted patients, thereby setting the stage for more effective inpatient or outpatient treatment.
Buprenorphine is available in two forms: a sublingually (under the tongue) administered tablet containing only buprenorphine (Subutex), and a sublingually administered tablet containing buprenorphine and the opioid antagonist (blocker) naloxone (Suboxone). Suboxone eliminates the danger of abuse of the opioid component of the medication: administered sublingually, only the buprenorphine is absorbed, but if the patient attempts to inject Suboxone, the opioid antagonist blocks the effect of the buprenorphine. Subutex and Suboxone are manufactured by Reckitt-Benkiser.
Perhaps the most important feature of the Drug Abuse Treatment Act and the availability of Subutex and Suboxone, is that it gives the ability of physicians to treat addicts in the privacy of their office. Patients no longer need to travel to substandard clinics to receive help for their addiction. As mandated by the DATA, physicians wishing to prescribe buprenorphine must complete the instructional course on the protocol for Office-based Opioid Treatment given by the Center for Substance Abuse Treatment. A listing of certified physicians can be found at www.buprenorphine.samhsa.gov.
Suboxone has been available for about one year. The results have been staggeringly positive. In the past, many opioid addicts attempting to achieve sobriety by the old methods (medical detox or “cold turkey”) failed to complete their detoxification. Now those patients are completing detox and entering treatment. Patients prescribed Suboxone are reporting that for the first time they feel some hope.
What Is Suboxone?
Suboxone is an opiate medication that keeps opiate addicts from feeling drug cravings and withdrawal symptoms.
How Does Suboxone Work?
When an opiate addict tries to quit using, the opiate receptors in her brain become empty, and this causes opiate withdrawal symptoms. Suboxone works by filling these opiate receptors in the brain, ending feelings of drug withdrawal and drug cravings.
How Does It Differ From Methadone?
Suboxone shares many similarities with methadone.
- Both medications are long lasting opiate drugs that are used to treat opiate addiction
- Both work through opiate substitution
- Both medications work at therapeutic doses by suppressing withdrawal symptoms and drug cravings, without inducing intoxication
Although these medications share many similarities, there are also important differences, and as a consequence of these differences, methadone users need to travel to a clinic each day to take their medication, while Suboxone users can take home a month’s supply.
Two significant differences between the medications are:
- Suboxone works as a partial opiate agonist, while methadone is a full agonist
- Suboxone is a medication with 2 active ingredients, buprenorphine and naloxone. Buprenorphine is the primary active ingredient – the opiate – and naloxone is added to the formulation to reduce the abuse potential. Methadone, by contrast, has no additives to reduce its substantial abuse potential.
A drug works in the brain by attaching to a neural receptor like an exact key in a matched keyhole. Drugs that are partial agonists can only partially turn that key, while full agonists can turn it completely. Significantly, this means that Suboxone, as a partial opiate agonist, can only deliver a limited effect – it can deliver enough to the opiate receptors to stop you from feeling withdrawal symptoms but it cannot deliver enough to get someone with an opiate tolerance high; no matter how much they take.
Methadone is a full agonist and there are no limits to its effects (other than overdose). Someone with an opiate tolerance can take a high dose of methadone and feel a significant intoxication. Methadone, therefore, has a higher abuse potential.
Suboxone contains the medication additive naloxone. When you take Suboxone as directed, by dissolving it under the tongue, the naloxone is not activated and produces no effect, but if try to inject Suboxone, the naloxone enters the brain and immediately cancels the effects of any opiate drug; which can send someone with an opiate tolerance into a sudden opiate withdrawal.
As a partial opiate agonist and with the addition of naloxone, Suboxone has a considerably lower potential for abuse and diversion, and because of this, doctors are permitted to prescribe the medication in month long take home doses.
Can Suboxone Cause Precipitated Withdrawal Symptoms?
Suboxone can cause precipitated withdrawal symptoms (induced withdrawal) in 2 ways:
- If abused, the naloxone in the formulation cancels the effects of all opiates – leading to immediate feelings of opiate withdrawal.
- If Suboxone is taken by someone with an opiate tolerance too quickly after a last dosage of opiates (oxycodone, heroin, etc.) the Suboxone pushes out these other full agonist opiates from the brain’s opiate receptors and causes a sudden lesser activation. This sudden decrease in opiate receptor activation can lead to feelings of withdrawal. For this reason, opiate addicts must wait until already feeling symptoms of opiate withdrawal prior to taking a first dose. This can range from 12 hours to a matter of days, depending on the drug of abuse.
Will Suboxone Work for Everyone?
Not everyone will find that Suboxone provides sufficient withdrawal symptoms relief.
As a partial agonist medication, Suboxone has what is called a “Ceiling Effect”. Increasing the dosage of Suboxone will lead to increasing effects until this ceiling is reached; and above this ceiling, increasing the dosage has no greater effects.
Some people find that Suboxone cannot provide them with sufficient withdrawal symptoms relief. These people will need to take methadone to feel relief from withdrawal pains.
The longer and more severe the opiate addiction, the greater the odds that methadone will be required.
What’s the Duration of Treatment?
Some people take Suboxone for days, some people for months, others for years – you take it for as long as you need to.
Suboxone is most commonly used as a form of opiate substitution maintenance treatment, in which the patient takes suboxone until he or she demonstrates a readiness to taper down and quit.
Taking Suboxone allows a person to get a life back on track, to develop solid sober support systems, to re-engage in school or work and to reconnect with a life outside of getting high. People who get off opiates once working from this stable foundation of sobriety have a much better likelihood of staying off opiates.
Some people feel ready to start tapering down after a matter of weeks, others take much longer and some others maintain on Suboxone indefinitely; there is no right or wrong answer, only a right for you answer. You take this medication for as long as you need to, and get off when you’re ready to.
What are the Side Effects?
Suboxone use can sometimes cause side effects, just like most prescription medications. Some of the side effects sometimes reported with Suboxone use include:
- Feelings of weakness
- Nausea or vomiting
- A reduction in sexual desire
If taking the medication, you need to read the information that comes with the drug to learn about the signs and symptoms of more serious but rarely occurring drug effects or allergic reactions.
Are there Safety Issues?
As a partial opiate agonist, Suboxone is a much safer drug than methadone, especially when used as directed.
Using Suboxone can be dangerous:
- When mixed with alcohol or benzodiazepines
- By injection administration
- When used by someone who is allergic to the medication
- When used by someone with severe liver damage
What are the Withdrawal Symptoms?
Stopping the use of Suboxone suddenly leads to a withdrawal syndrome. Suboxone users generally try to minimize the severity of this syndrome by tapering down their daily dosage very gradually, over time. Although Suboxone withdrawal symptoms are uncomfortable, the withdrawal off methadone is considered to be far more severe. Many methadone users will in fact transition onto Suboxone when trying to quit.
Suboxone withdrawal symptoms can include:
- Restless Legs
- Vomiting and nausea
- General muscle aches and pains
Symptoms will last with moderate severity for about a week after quitting, and diminish after that time over additional weeks. The experience people have in withdrawing off Suboxone seems to vary greatly.
Where Can I Find a Suboxone Doctor?
Not every doctor can prescribe Suboxone. Doctors need to apply for a special license and attend a training seminar to treat opiate addicts with the drug, and each doctor is limited in the number of patients she can treat. Call 877-975-1243 to find a suboxone doctor in your area.