A Very Brief History of Suboxone
Suboxone was initially marketed by the British company Reckitt Benckiser as a pain reliever for chronic pain.
It proved to be very effective in small doses; however, because of its chemical composition, it did not produce the same euphoria that other opioid medications (narcotic medications) did and was believed to be at less risk for abuse.
The drug of choice at that time to assist with recovery from heroin addiction was methadone, but methadone also carried a risk of addiction. Researchers found Suboxone was also an excellent candidate for opioid replacement therapy (a drug that can be used to decrease the physical withdrawal from opioid drugs as people attempt to recover from opioid addiction). Suboxone became legal in the United States in 2000 and was approved for treatment for opioid addiction in 2002. It still may be used for pain management, especially for people with opioid addictions.
The United States Drug Enforcement Agency rates Suboxone as a Schedule III drug, meaning that it is believed to have a moderate to low potential for addiction and can only be purchased legally with a prescription from a physician.
How Suboxone Works
Suboxone is a medication designed to treat addiction to opioid drugs (narcotic drugs), such as morphine, heroin, oxycodone, and other narcotic drugs. Two other medications, methadone and naltrexone, were also developed to treat addiction to narcotic drugs; however, Suboxone is quite different than these drugs.
- Buprenorphine, the more significant ingredient, is a partial opioid agonist.
- Naloxone is an opioid blocker.
According to Steven Stahl, MD, the author of Stahl’s Essential Psychopharmacology , a partial opioid blocker, like buprenorphine, is an opioid drug that creates less of an effect than would be experienced with full narcotic drugs, such as oxycodone, morphine, or heroin. Thus:
- When people take Suboxone, they may feel some sensations of pleasure and pain relief but not to the same extent as with a full opioid agonist.
- The notion here is to trick the brain into experiencing the effect that a complete opioid agonist, such as heroin, would produce by locking onto the receptors in the brain and thus suppressing the withdrawal effects and cravings related to the narcotic drug.
- Buprenorphine is long-acting and binds to the same receptors that the narcotic drug does for a full 24 hours (see below); therefore, even if one took heroin after taking Suboxone, the heroin could not bind to the receptors in the brain for that time period.
- In addition, taking buprenorphine also results in what is commonly called a ceiling effect, such that if one continues to take more Suboxone, the effects are not additive.
- Taking additional Suboxone will not allow the person to get higher on the drug, which is an advantage over similar drugs such as methadone (which is a full opioid agonist). This also makes it much harder to overdose on Suboxone.
Naloxone, an opioid antagonist, is also a medication used to treat addiction to narcotics that fit perfectly onto the opioid receptor cells in the brain. When Suboxone is taken as directed, in tablet form and dissolved under the tongue:
- The naloxone component is not absorbed into the bloodstream of the person taking it.
- However, if an individual were to grind up Suboxone and snort it, or inject it into the bloodstream directly, the naloxone component immediately locks on to the opioid receptors in the brain and knocks out any opioid drugs attached to the receptors.
- This will trigger an immediate opioid withdrawal syndrome (in people with physical dependence on opioid drugs) that will result in the person becoming ill.
- The addition of naloxone is designed to keep people from snorting or injecting Suboxone to get high.
Suboxone is relatively long-acting. Based on the current available research performed:
- Buprenorphine has an estimated mean elimination half-life that ranges from 24 to 42 hours.
- Naloxone has a mean elimination half-life that ranges from 2 to 12 hours.
Common Side Effects
Based on available double-blind, placebo-controlled clinical research findings, it appears that Suboxone has relatively fewer side effects than other medications used for opioid addiction. The following side effects appear to be most common:
- Sensations of feeling dizzy or lightheaded
- Fever or chills
- Flushing or redness, most often on the face and neck
- Lower back pain
- Pain on the sides of the torso
- Difficulty or painful urination
- Runny or stuffy nose
- Depression like symptoms (tearfulness, depressed mood)
- Abnormal thinking
- Mild insomnia
- Decreased blood pressure
- Decreased heart rate
- Cold and clammy skin
- Flaccid muscles
- Allergic reactions that affect breathing
- Severe respiratory distress
- Cardiac arrest
Can a Person Abuse or Become Addicted to Suboxone?
Despite claims made by the manufacturer that Suboxone has built-in safeguards towards reducing or eliminating the potential for abuse and addiction, there are reports of illegal sales of Suboxone on the street as well as a rise in the number of cases admitted to emergency rooms with signs of Suboxone overdose. These are both indications that there is a trend, even if it is a minor trend, for Suboxone abuse. Even though Suboxone is a difficult drug to abuse, the evidence suggests that Suboxone abuse does occur.
Based on available research, the ceiling effects of Suboxone appeared to top out at around a dose of 32 mg, which indicates that higher doses than that will not produce any measurable effects, such as mild euphoria. The naloxone component to Suboxone indicates that it is pointless to inject the drug in most cases; however, there are reports of Suboxone being ground up and snorted. Moreover, street sales of Suboxone indicate that it is being sold without a prescription, making it illegal. This is a form of abuse and also opens the door for it to be mixed with other drugs, such as alcohol or benzodiazepines. It appears that benzodiazepines may be often used in conjunction with Suboxone, indicating serious cases of abuse.
Mixing Suboxone will alcohol or benzodiazepines enhances the effects of both the drugs and increases the probability for adverse consequences. These consequences are typically potential serious respiratory problems and even respiratory failure. Mixing these drugs together increases the potential of an overdose.
Of the side effects of abuse that may occur, the following are potential side effects that one should look for if one suspects a person is abusing Suboxone and/or alcohol or benzodiazepines:
- Extreme drowsiness
- Slurred speech
- Loss of consciousness
- Poor decision-making
- Increased risky behaviors or impulsiveness
Other signs that someone might be abusing Suboxone include:
- Mixing Suboxone with other drugs such as alcohol
- Loss of interest in regular activities
- Dishonesty and secrecy regarding the person’s use of Suboxone
- Sudden changes in habits
- Sudden changes in mood
- Taking larger doses of Suboxone or taking it more frequently than prescribed
- Using Suboxone without having a prescription
- Buying Suboxone illegally
- Spending more time trying to get Suboxone
- Declining academic or work performance
- Negative consequences in personal relationships as a result of using Suboxone
- Wanting to stop using the drug, but not stopping
- Getting angry when people mention that use of the drug might be too frequent
- Changes in physical appearance, such as being disheveled or changes in one’s grooming habits
- Changes in one’s presentation, such as slurred speech, extremely slow patterns of thinking or responding, or significant memory issues
While it is most likely difficult to develop an addiction to Suboxone alone, people taking it for any reason may develop a mild physical dependence on the drug, due to the nature of main ingredient in the drug, buprenorphine.
Differentiating between Addiction and Physical Dependence
The terms addiction and dependence are often used interchangeably; however, there is a real distinction between having a physical dependence on a specific drug and being addicted to the drug. Moreover, a great number of individuals develop a physical dependence to drugs they are taking for legitimate therapeutic reasons as in the case of an individual with severe rheumatoid arthritis who takes narcotic painkillers in order to function daily. A person can develop a physical dependence on a particular medication and not be addicted to it.
Physical dependence consists of physical qualities of tolerance and withdrawal:
- Tolerance refers to a physical (even psychological) change as a result of taking a particular drug or medication, such that higher and more frequent concentrations of the drug are needed to achieve the effect that occurred when one started taking the drug.
- Withdrawal refers to a series of symptoms, both physical and psychological, that occur when a person abruptly stops using a drug or cuts down on the dosage of the drug.
Addiction refers to a chronic condition that can be physical, psychological, or both, and that is characterized by nonmedical use of the drug that results in impaired control over drug use, or compulsive use of the drug despite suffering negative consequences for using it. Addiction may or may not include the symptoms of tolerance and withdrawal.
Thus, it is important to remember that everyone who uses Suboxone will most likely develop at least a low-level physical dependence on the drug, depending on the amount taken and length of use; however, due to the chemical makeup of Suboxone, becoming seriously addicted to it is rare.
- Withdrawal from Suboxone
If a person demonstrates symptoms of withdrawal, these may often suggest that the person is suffering from substance abuse, as even individuals with prescriptions who are physically dependent on the drug should not, under normal treatment conditions, experience significant withdrawal symptoms.
Buprenorphine, the main active ingredient in Suboxone, is an opioid drug and discontinuing it abruptly will result in physical withdrawal, although the withdrawal effects may be significantly less intense than withdrawal from other opioid drugs such as morphine, heroin, or even methadone. Nonetheless, according to research, the following physical effects can occur from withdrawal from Suboxone:
- Mood swings
- Low grade fever
- Muscle cramps
- Aching muscles
Typically, just one of these symptoms will not indicate withdrawal syndrome; however, three or more symptoms occurring in an individual who has stopped using Suboxone could be a sign of physical withdrawal. Of course, several symptoms relate to other physical issues, such as an infection or illness, and it is important to rule those potential conditions out.
- Approach a Family Member Who May Be Abusing
Attempting to help a loved one recognize that abuse of a drug is occurring can be quite challenging. Perhaps one should only expect to foster awareness in someone suspected of having a drug abuse issue during the first conversation. While many addiction professionals and researchers consider substance use disorders chronic conditions similar to diseases, the individuals who suffer from substance use disorders are often unable to objectively view their situation in the same light as people around them view it. Even if the individual is using Suboxone that is legitimately prescribed, the person may still be abusing it.
In order to approach someone regarding drug abuse or addiction, an individual should:
- First fully understand the motivation for the discussion
- Understand that the responsibility for change lies within the person with the problem, not with others
- Understand that people with substance use issues are often unable to see their issues in the same light that others do
- Try to be objective and point out issues of behavior that suggest an abuse problem
- If at all possible, not be confrontational
- Expect resistance and try and roll with it
- Not threaten
- Attempt to keep the conversation as positive as possible
- Repeatedly express concerns and avoid accusations
- Whenever possible, frame concerns in the form of questions
- Be respectful
- Continue to express concern and understanding
- Be willing to end the conversation if the person gets overly upset
- Offer to be available for help or discussion at a later time
If the initial attempt to discuss the issue with the person fails miserably, or if the person is engaging in potentially reckless or self-damaging behaviors, it is advisable to speak with a physician or substance abuse counselor, and schedule a formal intervention for the person. People should generally not schedule an intervention without enrolling the assistance of a trained professional.
What Is an Intervention?
An intervention is a more formal approach to confront someone whose behavior is affecting others or may be self-damaging. Typically, the people involved in interventions consist of relatives and close friends as well as a professional, such as an interventionist or family mediator.
- An intervention is a deliberate and more formal process that introduces the need for change.
- An intervention should be carefully planned and individuals contributing should be carefully chosen.
- Interventions attempt to confront individuals in a nonthreatening manner that allows them to see how their behavior affects themselves, their family members, coworkers, friends, and others close to them.
- Interventions for substance abuse or addiction issues typically utilize the help of a addiction treatment professional or interventionist as well as close friends and family members.
- People participating in the intervention take turns discussing the self-destructive behavior of the person in question and how it affects them. The interventionist helps guide the conversation and keeps things under control.
- The main objective of an intervention is to get the person to listen and to at least consider that help may be needed.
Getting off Suboxone
Discontinuing Suboxone is not much different than discontinuing any other opioid drug. There are specific concerns and issues regarding stopping the drug, and anyone who is going to attempt to discontinue Suboxone use should do so under the supervision of a physician. A person should not try to discontinue the drug alone due to the potential withdrawal effects and other unforeseen medical issues that may arise, such as increased physical pain that was controlled by using the drug. Physicians are best equipped to handle these issues.
- Typically, a physician will initiate a medical detox procedure and taper the dose slowly so the person can adjust.
- Generally, when an individual has a very low dosage of daily intake (e.g., 2 mg per day), the physician will withdraw the drug.
- During the detox/tapering portion, the individual should also begin substance abuse therapy.
- As the person successfully begins a transition to living without the drug, support groups can be beneficial to help recovery maintenance.
In cases where Suboxone abuse is performed in conjunction with use of other drugs, such as alcohol, procedures to initiate the discontinuation of those drugs will also need to be implemented. Medical detox ensures that the individual can safely withdraw from all substances of abuse.
Discontinuing Suboxone is similar to discontinuing other opioid drugs; however, there are some specific issues with Suboxone abuse that can complicate the situation. Individuals who receive support and understanding can be successful in their efforts to discontinue using Suboxone, whether their use of the drug stems from attempts to discontinue other opiate drugs or whether their use of Suboxone itself represents a substance use disorder.