Suboxone and it's special qualities
Suboxone is a combination of two medications – buprenorphine, which is a partial opioid agonist, and naloxone, an opioid antagonist. They are called opioids instead of opiates because they are synthetic (not derived from naturally occurring opiates). Commonly the term opiates is used for both opiates and opiods although this is techically not correct.
Agonists are compounds that stimulate specific receptors. For example oxycodone, morphine, hydromorphone, fentanyl and methadone are all opiate or opioid agonists.
Partial agonists like buprenorphine are drugs which only partially stimulate a receptor. One of the advantages of partial agonists is safety – increasing the dose past a certain point may not cause an additional effect because even if most of the receptors are occupied they are still only partially stimulated. Note that buprenorphine acts as a partial gonist with respect to respiratory depression and preventing withdrawal symptoms but it acts as a full agonist with respect to treating pain. Buprenorphine is as good as any opioid for treating pain but would need to be used 3-4 times dailyfor this purpose.
This characteristic is noted with buprenorphine. When 16mg is taken daily 92% of the opiate receptors in a persons brain are occupied. Additional doses have very little additional effect on respiratory depression (all opiates can cause respiratory depression). Therefore it is more difficult to overdose on buprenorphine than opiate agonists, including methadone.
There is an additional aspect of buprenorphine's pharmacology that makes it both useful in the treatment of addiction and at the same time more difficult to use. It has a very high affinity to opiate receptors. This means that it binds more strongly to opiate receptors that other opiates.
The high affinity is useful because if a Suboxone patient tries to use full agonists when they are on Suboxone the agonists have very little or no effect. Because the patient does not get high the behavior (using the agonist drug) is not reinforced in the patient's brain – reinforcement is something that would delay recovery from the addiction. Most patients find this characteristic of buprenorphine helps them quit opiates sooner.
The high affinity of buprenorphine makes Suboxone more difficult to use. The patient must be in moderate withdrawal before Suboxone is administered or the high affinity to opiate receptors coupled with the partial agonist properites of buprenorphine leads to opiate agonists that are present in the brain being replaced with a compound that only partially stimulates the receptor. This leads to the rapid development of withdrawal symptoms – a complication known as precipitated withdrawal. So, if you are in moderate withdrawal Suboxone can be started and you will soon feel better. If you are not in at least moderate withdrawal, you may feel worse. More about this when we discuss the induction.
Suboxone is allowed to dissolve under the tongue – the buprenorphine is not effective if the pill is swallowed only if it absorbs under the tongue. The naloxone is only active if the pill was liquefied and injected – naloxone would block any effect that the buprenorphine would have if injected. This is a safety feature.
How Suboxone helps
Suboxone is an opioid and therefore effective in reducing the craving to use opiates and the symptoms of opiate withdrawal. Suboxone is used to treat addiction to other opioids, for example codeine, oxycodone, hydromorphone, fentanyl, morphine and heroin. It is about as effective as methadone. It is not useful in treating an addiction to cocaine or crack, methamphetamine (speed), MDMA (ecstasy), benzodiazepines (valium and others), marijuana or alcohol.
Suboxone can be effective whether you typically inject, snort or swallow opiates. Several scientific studies have proven that addicts on an opioid maintenance program are less likely to have legal or medical problems and are more likely to hold down a job, stay in school and keep their family together. The evidence is overwhelming – the patient benefits but so do their family and society.
Who can prescribe Suboxone
The College of Physicians and Surgeons of Ontario (CPSO; the licensing authorioty for all medical doctors in Ontario) has made recommendations for which doctors should prescribe Suboxone. The CPSO recommend that to prescribe Suboxone a doctor should:
- have taken a specific Suboxone training course,
- have experience in treating opiate addiction,
- take continuing medial education in the treatment of opiate addiction, and
- and in most cases should probably be methadone prescribers so that patients may be offered a choice
The doctors at BMC meet all these requirements for Suboxone treatment.
How is Suboxone started?
Starting Suboxone is termed an Induction. Suboxone Induction should only be attempted by a physician trained in the procedure. Because Suboxone is a partial agonist it may put people dependent on opiates into a precipitated withdrawal. Precipitated withdrawal is a rapid onset and intense withdrawal caused by taking Suboxone when you have residual opiate drugs in your system. Before the induction the physician will ensure you are in a partial opiate withdrawal state and then slowly introduce Suboxone to your system over several hours. You will likely spend most of the morning at our clinic, be reassessed at the end of the day and checked again the next morning. Your dose will be adjusted over this 24 hour period and then you are reassessed at a week later in most cases.
How is Suboxone taken?
Suboxone is a sublingual (under the tongue) tablet taken once a day. Initially patients must go to a pharmacy every day to get their dose. The pharmacist will witness the doses being taken. As they progress in the treatment program they will be allowed to take doses home to take on their own. Likewise, initially they attend clinic once per week. As they progress they attend clinic less often. Our goal at BMC is to have the treatment help you achieve your goals in life, not interfere with them.
How much does Suboxone cost?
Suboxone is covered by the provincial drug plan in Ontario (ODB) in special situations:
- you have had an adverse reaction to methadone
- you have a medical contraindication (medical concern) for methadone
- you have failed methadone maintenance treatment
- you are on benzodiazepine medications
- you are alcohol dependent or abuse alcohol
- you live in a remote location – unable to get methadone readily
Suboxone is also covered by NIHB (Indian Affairs) and most 3rd party drug plans. If you are not eligible for any of this coverage methadone may be a better choice unless you are likely to be on a low dose of Suboxone – then the price may be less than methadone. A typical start dose of Suboxone is costs about twice that of methadone.
Effects & Side Effects
Euphoria (feeling high) or sedation or nausea is possible if too high a dose of Suboxone is taken. Typically patients feel no effect except a decreased need for opiates. Your stable dose is achieved over 24 hours to a few days (compared to a few weeks with methadone). Once stabilized patients do not get “high” and they do not suffer withdrawal or craving for opiates. Patients usually do not get high if they take other opiates because Suboxone maintenance blocks the euphoric effects of these drugs – this helps to decrease the desire to use opiates.
Suboxone is useful to prevent withdrawal because it has a long duration of action. For most people a single dose prevents withdrawal for more than 24 hours. By slowly decreasing the dose over weeks or months (more typical) patients can become opiate free without having to go through withdrawal – this is called a taper. Patients at BMC are never forced to go off Suboxone and a few do prefer to stay on chronic therapy.
Some people get some side effects but overall Suboxone is well tolerated. Most common side effects are constipation (typical of all opiates), dizziness or drowsiness or headache. Weight gain, sweating and sexual side effects are much less common than with methadone, especially higher dose methadone. Withdrawal symptoms like abdominal cramps, nausea, diarrhea, insomnia, restlessness, irritability, anxiety and muscle or joint pain may be part of the induction phase but resolve quickly once the patient 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.
Suboxone is not approved for use in pregnancy however the active component, buprenorphine, is safe in pregnancy. The concern over Suboxone in pregnancy may be overstated but BMC does switch pregnant patients from Suboxone to Subutex (the buprenorphine only medication). Subutex usually is available within 2-3 weeks of application for the medication by BMC. It is beleived that Neonatal Abstinence Syndrome (baby withdrawal) is less severe and requires less treatment for babies born to mothers on burpenorphine vs. methadone. Please see the pregnancy related FAQ's.
A previous concern about Suboxone compared with 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 or methadone or buprenorphine for maintenance. The amount of extra opioids needed to treat pain compared with patients that are not on long term opioids is about the same regardless of whether you are on methadone or suboxone. If you have surgery or a procedure booked please discuss this with your BMC physician. We are available to talk with your surgeon, dentist or anesthetist.
Suboxone is a very good pain agent but need to be used 3-4 times per day. This treatment is not covered by ODB, NIHB nor 3rd party drug plasn at this time.
Will I become addicted to Suboxone?
Patients taking Suboxone are already physically dependent to opioids – stopping it will cause the uncomfortable physical symptoms of withdrawal. However, by definition these patients are not addicted to Suboxone even though they are physically dependent – addiction involves not only a physical need for the drug (dependence) but several undesirable behaviors that a person develops to help them get the drug. See the section in key concepts.
In Ontario patients taking Suboxone follow similar rules with respect to clinic visits, urine testing and restrictions in carry home doses as Methadone patients but there are some differences. Overall Suboxone maintenance is probably easier than methadone maintenance in the longer term – talk to the BMC physician. Certainly it is easier to travel with.