What is Suboxone?
- Suboxone is a specially-formulated combination medication designed for induction and maintenance treatment of opioid dependence. The addition of naloxone to this combination therapeutic was made to deter abuse of the treatment drug itself.
- Suboxone is used for withdrawal management in early recovery and longer-term treatment of addiction to opioid drugs such as heroin and prescription painkillers such as oxycodone and hydrocodone.1 According to the
- Substance Abuse and Mental Health Services Administration (SAMHSA), Suboxone is meant to be used in combination with behavioral therapies to provide a “whole-patient approach to the treatment of opioid dependency.” 2
Buprenorphine and Naloxone Combine to Fight Addiction and Dependence
Buprenorphine has some advantages over methadone, another medication widely used in the treatment of opioid addiction. While methadone must be dispensed from an opioid treatment program (OTP) specially certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), buprenorphine may be prescribed and dispensed from certain doctors’ offices (from physicians who have qualified for a special waiver). Secondly, unlike methadone which is a full opioid agonist, Suboxone combines a partial opioid agonist (buprenorphine) with an opioid antagonist (naloxone) to deter abuse and decrease the risk of drug diversion. For some practitioners, this makes Suboxone the preferred treatment for those at risk of abusing their treatment medications.3
As a partial opioid agonist, buprenorphine:2.4
- Elicits opioid effects, such as pain relief, but not to the same extent as full agonists such as heroin.
- Relieves opioid withdrawal symptoms and cravings.
- Competitively binds to mu-opioid receptor sites to minimize activation of these receptors by other opioid agonist drugs, thus decreasing the chance of a euphoric high elicited by additional opioid use.
What is the Ceiling Effect?
- Buprenorphine also has a “ceiling effect.” This means that increasing doses of the drug will result in a concomitant increase in opioid effects only to the extent that the effects “ceiling” is reached. This point is reached with only moderate dose increases, making the drug less potentially rewarding/reinforcing during attempts to misuse it and safer in the event of an overdose.
- The secondary ingredient, naloxone, remains inactive when the drug is used as directed (i.e., sublingually); however, when users attempt to misuse the drug by injecting it, the naloxone becomes active, blocks the opioid effects, and brings on opioid withdrawal.2 There is also some evidence that snorting the drug may also produce precipitated withdrawal.5
- However, as safe as Suboxone may be, there is still some potential for abuse.3
- According to the United States Drug Enforcement Administration, Suboxone is a Schedule III substance, indicating that it has some abuse potential (albeit less than schedule I drugs like heroin, or schedule II drugs like many prescription painkillers), may lead to moderate physical dependence, or could result in high psychological dependence. As a scheduled drug, Suboxone can only be legally obtained with a prescription.1
- SAMHSA states that buprenorphine may be abused, especially by those who are not opioid-dependent and otherwise unlikely to experience any of the buprenorphine-induced withdrawal common in people who are significantly opioid dependent (and, likely, quite tolerant to even full agonist drugs).2 The Suboxone drug label warns of the potential for abuse and diversion and also warns of the dangers of misusing the drug with other drugs that depress the central nervous system and slow breathing (such as benzodiazepines or alcohol). Overdose deaths have been reported when people abuse Suboxone in combination with these types of substances.6
- While the naloxone is added to prevent abuse by snorting or injection, it is not a perfect system. The buprenorphine in Suboxone binds more strongly to the mu-opioid receptors than naloxone and also has a longer elimination half-life than naloxone. In such a theoretical situation, the buprenorphine component could continue to exert some opioid activity even when naloxone is present and, of course, continue to do so after the naloxone has been cleared by the body.4
- Furthermore, there is some evidence that naloxone does not always have the intended antagonizing effect designed to prevent abuse.7
Can You Get Addicted to Suboxone?
- Suboxone has a lower abuse potential than many other opioids; however, compulsive misuse of and/or addiction to this medication is not unheard of. A Suboxone high may be especially powerful and rewarding for someone who is not yet opioid-dependent and/or who has never abused opioids before and may feel akin to the notoriously addictive first heroin high.
- However, even people recovering from opioid addiction with the help of Suboxone may begin to abuse their prescribed supply of the treatment medication by making attempts to snort or inject it to achieve a high more similar to what they are accustomed to. Dr. Steven Scanlan, a Florida psychiatrist and addiction specialist, rejects the notion that the drug can’t be shot up or snorted, saying he’s seen dozens of people who’ve admitted to abusing the medication in these ways.8
- Abuse of this drug may indeed reinforce the development of addiction, which is marked by the compulsive use of a drug despite the adverse consequences.9
- Both regular use of and abuse of Suboxone can result in physical dependence on this treatment drug. Physical dependence often coincides with, but is distinct from, addiction. While on Suboxone treatment, a person may continue to have a certain amount of physiological opioid dependence but no longer display behaviors associated with opioid addiction.10
- Dependence is a normal physiological phenomenon that develops with the regular use of a substance; your body adapts to the regular presence of a drug in a way that it essentially begins requiring it to function normally. When the drug is discontinued, your body will experience a withdrawal syndrome which.
- Addicted or not, anyone physically dependent on a substance is likely to experience some degree of withdrawal when attempting to go off the drug. In the case of Suboxone, because it is an opioid, withdrawal may be painful but probably won’t be particularly dangerous.
There are several factors that will influence both the length of time and the severity of symptoms that occur during the withdrawal process. These factors include:11
- Regular dose: Consistently higher-dose use may result in more a severe withdrawal.
- Duration of use: A longer duration of Suboxone use is likely to result in the development of more physical dependence and a subsequently more difficult detox experience.
- Previous withdrawal experiences: Previously difficult withdrawal experiences may predict a more challenging withdrawal.
- Individual differences: Issues like mental health, physical health, life stressors, and community supports could all influence the withdrawal experience.
Tapering the drug slowly under the care of a physician will help to alleviate the symptoms of withdrawal.
Suboxone Withdrawal Timeline
For most people, Suboxone withdrawal symptoms will begin within 2-4 days and last approximately 10-20 days. The following is a typical timeline (individual experiences will vary):12,13
First 24-72 Hours: Withdrawal from buprenorphine (there is no withdrawal from naloxone) will be most intense in this time period and will usually peak in its intensity at around 72 hours since the last dose. The symptoms most common during this phase include:12,13
- Increased body temperature.
- Watery eyes.
- Dilated pupils.
Weeks 1 and 2: As withdrawal continues, the following symptoms are likely:
- Increased blood pressure and heart rate.
- Poor appetite and weight loss.
- Nausea and vomiting.
- Goose bumps.
- Pain in the muscles and bones.
- General feelings of discomfort and restlessness.
Weeks 3 and 4: By this time, the physical symptoms of withdrawal will likely have subsided, but many people still experience feelings of depression, general malaise, restlessness, lack of motivation, and cravings for the drug.
For many, the early withdrawal symptoms are similar to a bad case of the flu. The acute symptoms usually peak within a few days to a week as mentioned above; however, some people experience prolonged psychological symptoms for weeks or months after withdrawal ends, such as:14
- Dysphoric mood.
- Lack of ability to feel pleasure.
Withdrawal from Suboxone and other opioid drugs is not often life-threatening; however, it certainly may feel that way at its peak.11 During medical detox, staff can help to relieve your discomfort through the use of medications and supportive care.
How to Stop Taking Suboxone
- Anyone who is going to attempt to discontinue Suboxone use should do so with the help of a physician. The discomfort of an unmanaged opioid withdrawal may increase relapse risk, and other unforeseen medical issues may arise, such as increased physical pain that may have been somewhat lessened with Suboxone.11
- Even though Suboxone withdrawal is not usually dangerous, there are situations where the individual could experience serious medical issues such as dehydration resulting from vomiting and/or diarrhea or a worsening of an underlying cardiac illness.11 In a medically supervised environment, these symptoms can be addressed immediately.
- Typically, a physician will initiate a taper to allow the body to adjust slowly to lower and lower doses of the medication until eventually the drug can be discontinued completely without severe withdrawal symptoms.11
If the individual is addicted to Suboxone, substance abuse treatment should commence after detox is complete and will center around individual and group therapy.
- U.S. National Library of Medicine: DailyMed. (2018). Suboxone.
- The Substance Abuse and Mental Health Services Administration. (2016). Buprenorphine.
- National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide.
- Pharmacytimes.com (2016). A Brief Review of Buprenorphine Products.
- Middleton, L. S., Nuzzo, P. A., Lofwall, M. R., Moody, D. E., & Walsh, S. L. (2011). The pharmacodynamic and pharmacokinetic profile of intranasal crushed buprenorphine and buprenorphine/naloxone tablets in opioid abusers. Addiction (Abingdon, England), 106(8), 1460-73.
- U.S. Food and Drug Administration. (2010). Highlights of Prescribing Information.
- Whelan, P. J., & Remski, K. (2012). Buprenorphine vs methadone treatment: A review of evidence in both developed and developing worlds. Journal of neurosciences in rural practice, 3(1), 45-50.
- Matesa, Jennifer. (2011). The Great Suboxone Debate.
- Mulligan, Daniel. (2014). The Suboxone Addict Your Never Knew Existed.
- The National Alliance of Advocates for Buprenorphine Treatment. (n.d.). Is buprenorphine treatment just trading one addiction for another?
- Substance Abuse and Mental Health Services Administration. (2015). Detoxification and Substance Abuse Treatment.
- World Health Organization. (2009). Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Setting.
- Federal Bureau of Prisons. (2018). Detoxification of Chemically Dependent Inmates.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.