If you have been doing research on the topic of opiate addiction, you probably have come across a few different options and if you are like me, none of the options seem very appealing. Rehab is too expensive ($30,000 for 30 days, and up), it takes too much time and frankly is not what I needed. Rapid detox sounds like some sort of Inquisition-era torture where they put you under for 12 hours and then make your body go through a rapid detox…ummm, no thanks. Then there’s the acute care (hospital) detox where you just sit in a bed and take Xanax and Advil for 7 days after which they hand you a $6,000 bill. And finally, there is a drug called Suboxone (Or sometimes called by it’s generic active ingredient Buprenorphine) that is sort of a new-age methadone which helps you get off of opiates and then -or so the theory goes- you are able to taper down off of the Suboxone and that’s it! The slang for Suboxone is “Sub”…I call it the “rich man’s methadone”.
Well Dr. Earthman could probably discuss this topic a lot more eloquently (He prescribes Suboxone for some of his patients) but I’ll give you the basics and then if you have any further questions about this post or Suboxone, you can write into Dr. Earthman and ask him about it. By the way, the questions that we got last week were great so keep them coming. So let me give you a layman’s explanation of Suboxone to the best of my abilities.
Partial Agonist v. Full Agonist:
I have to talk about this first because its important for you to understand the basics about what is going on in your brain when you take opiates in order for you to understand how Suboxone works. I’m going to make it as general as I possibly can for the purposes of this discussion. When you take a pill like a Vicodin for instance, it releases chemicals into the brain that attach to your brain’s opiate receptors. When your brain’s opiate receptors are occupied by the right molecule, it signals your brain to release other chemicals that help relieve pain and can also cause that euphoric feeling or “high” that you can get when you take that Vicodin. For this reason, Vicodin, Oxycodone etc. etc. are considered “full opioid agonists.” [Note to "Chemists" out there. Please don't email me and get all technical about how I made a mistake on this molecule or how I mixed this or that up. I'm just trying to explain this process in general terms as if I were reading it for the first time...4th grade reading level ok?]. Suboxone is considered a “partial opioid agonist” because it binds to your brain’s opiate receptors, but it gives your brain slightly different instructions on what chemicals and processes to activate. That’s all you really need to know about that. I will explain what Suboxone/partial opioid agonists do below…read on.
Lesson Recap: Vicodin = “Full Opioid Agonist” Suboxone/Subutex/Buprenorphine = “Partial Opioid Agonist”
What is Suboxone?:
Suboxone is a brand name for a drug that is a 4:1 mixture of Buprenorphine and Naloxone. These partial opioid agonists send different instructions to your brain than full opioid agonists. In much the same way that a birth control pill fools a woman’s body into thinking it’s pregnant, partial opioid agonists fool your brain into thinking it is receiving its normal dose of opiates.
What Does Suboxone Do?:
As I explained above, the pain killers that you take or that you took are considered full agonists because they bind to those same opiate receptors in your brain and they potentiate (produce) a narcotic effect (the “high”) and help relieve pain. Suboxone is called a partial agonist because although it acts very much like a normal opiate, it does not produce the same “high” as pain killers. Thus, Suboxone is a very powerful pain-killer but it does not produce any of those narcotic effects that pain killers do. Since Sub masquerades as an opiate and your brain does not know the difference, a person is able to discontinue the use of their normal pain killers and take Suboxone without having to go through “complete” acute withdrawals. You “Substitute” your drug for Suboxone in order to avoid painful withdrawals…sort of. See below.
The added benefit of a partial agonist like Suboxone is that while you are taking it, your opiate receptors are “occupied” right? Therefore, it blocks any other opiates from producing any effects or giving your brain any other instructions. Just think of those opiate receptors in your brains as a bunch of tiny locks. You can’t activate or open those receptors if there’s already another key (the partial agonist/Sub) in those locks right? Ok, well I hope that you’re following me. In any case, if you’re on Suboxone, your Vicodin won’t work very well.
How Is It Taken?:
Suboxone is usually administered sublingually which means that it dissolves under your tongue. There are also transdermal patches available but I believe that the sublingual pill is the most popular application. The pill form comes in two different dosages (2mg and 8mg) and tastes like you’re eating a burned orange peel. Yum. Some people can’t stand the taste but I think it’s tolerable.
When Do You Take Suboxone:
Ok, so here’s the kicker. Let’s assume you are on 8 Norco 10/325’s per day, all of those opiate receptors in your brain are occupied by that drug. In order for Suboxone to work, those opiate receptors have to be open and available for the Sub to occupy. That means that a person who wants to begin Suboxone therapy must not take any opiates until those Norco’s are out of their system. As you know, if you stop taking the Norco’s for long enough, you will start to go into withdrawal. That’s because the withdrawal process is a physical manifestation of all of those opiate receptors being vacated. If we are using the same Norco analogy, you will not begin acute withdrawal for at least 12-14 hours. So…in order for the Suboxone to work, you must be in full-blast, goose-fleshy, shivering withdrawals before you take your first dose. This is very very important. If you take Suboxone before you are in full withdrawal, you will go into what’s called “precipitated withdrawal.” You really really don’t want this. So usually, one has to wait at least 24 hours before taking their first dose of Sub.
What Can You Expect When Taking Suboxone?:
After your first dose, it doesn’t take long for you to start feeling much much better and at first, the Suboxone might make you pretty drowsy and woozy. That goes away. Your doctor might start you off at a pretty high dose (12-16 mg’s) depending on your prior opiate intake and then you will taper down the dose until you find a happy medium that will not create any withdrawals. The key to your target dose of Suboxone is to take as little as possible without feeling sick from withdrawals. Remember, Suboxone is an opiate in almost every way; a very powerful one actually, so if you stop taking the Sub, you will go into withdrawals in much the same way that you did when you stopped taking your Norco’s. Suboxone has a longer half-life than a Norco/Vicodin so it will take longer for your withdrawals to begin but they will happen if you stop taking it. Usually when you’re on Sub, you won’t feel much, you won’t get any high and you won’t have much of an urge to take opiates.
How Long Do You Take Suboxone?:
This is up to you and your doctor but some people can get on Suboxone and immediately start tapering off. However, some clinicians believe that it is best for the patient to be on Sub long enough so that they don’t immediately fall back into the same pattern of drug use that they were in before. This makes sense to me. If you take Suboxone for say 6 months, all of those previous triggers and addictive behaviors have time to fade away and you’ll be able to establish a new “lifestyle” and schedule. You also might remain on Suboxone in order to control any chronic pain that you have. I’ve seen people who have been on Suboxone for periods of over 5 years which I guess means that the person plans to remain on Sub for the rest of his or her life. I’ve also heard of people who go on Sub and then immediately begin to taper until they are completely off and free of any medications.
That sounds great right? Well, sort of…lets examine the “Pro’s” and Con’s of Suboxone.
The Pro’s of Suboxone:
1. Administered under the care of a licensed physician who has undergone additional training and accreditation for prescribing Suboxone.
2. Does not have the same narcotic effects and provides a stable means to permanently quit your opiate addiction.
3. Is very hard to overdose on (unless taken intravenously or with Benzodiazepines) and helps block other opiates from having any effect on your brain.
4. Can be tapered with your doctor in a controlled manner. Tapering is a lot easier to accomplish due to the fact that it has mild narcotic effects.
5. Provides a way to partially avoid a longer acute withdrawal from the drugs you were taking previously.
6. Is “accepted” by most major insurance carriers.
7. It’s relatively easy and painless to take other than the bad taste.
8. Does not have any really serious side effects…sort of.
The Cons of Suboxone:
1. It is very, very expensive. Even if your insurance “covers” it, they are going to make you pay a lot more for it than your normal co-pay, expect to pay about 300 bucks a month with insurance and about 300 bucks a week without insurance. That’s not including the cost of your monthly doctor’s visit. Ouch!
2. It’s mildly addictive. I know, I said that it doesn’t have the same narcotic effects that other opiates have but it does have a calming and slightly…um…nostalgic opiate euphoric effects. This is my personal experience and others may be different but I got a little bit of a high from it. I have heard others that have gotten really really hooked on it.
3. You are substituting one drug for another and you have to ask yourself if you are getting closer to your goal by doing so. The clinical strategy with Suboxone is virtually the same as methadone which is essentially to “stabilize” and then “sustain” the patient until he or she is ready to get off of it.
4. There ARE withdrawals from Suboxone. Since Suboxone is a relatively new drug, there’s not much data on the long-term effects of the drug or the withdrawals. The common wisdom is that Suboxone withdrawal is very similar to opiate withdrawal except that it is a bit milder and lasts up to a month as opposed to 10-12 days like Vicodin. There is a syndrome called P.A.W.S. (Post Acute Withdrawal Syndrome) that is commonly associated with Suboxone and it consists of prolonged lethargy, depression and insomnia. There are entire websites (i.e. www.subsux.com) dedicated to Suboxone withdrawal so it is not a small issue
5. Many people who have used Suboxone will find it too expensive and then transfer to methadone treatment since it’s cheaper. Trust me, you do not want to be on Methadone! You have to go to a clinic every day (gag) to pick up your dose and the withdrawals are horrible. In my opinion, you might as well go back to Vicodin if you’re thinking about Methadone.
6. Suboxone doesn’t have many side effects but the ones that it does have are acute. Industrial strength constipation that will make you want to drink Drano (for God’s sake this is a joke! Don’t drink Drano). It gives you munchies for sweets and whatever weight you are now just tack on 10% after you get on Suboxone. It can also make you very very sleepy and when I was on it, I drank about 4 cups of coffee and 5 cokes a day to stay awake which caused…insomnia.
7. Did I mention it’s very expensive? You also need to find a doctor that will administer it to you every month so factor in the office visit co-pay or out-of-pocket costs into the total cost of the treatment.
My Personal Conclusion/Opinion:
Please remember that I am just one person and my thoughts below just reflect my experience with it and other people’s experiences that I have witnessed. As I mentioned before, Suboxone is in my opinion a “rich man’s” methadone although it is far superior to methadone in many ways. As you know from my many posts and blogs, I encourage everyone to quit painkillers in any way that they can. Whatever works. For some people, Suboxone has been a God-send and they have been able to begin the therapy and get off of it with no problem. It’s safe if it is taken as directed and under the auspices of a licensed physician. It is very effective at reducing any cravings for opiates and does a good job controlling chronic pain.
However, it’s price makes it very hard for the average Joe to get on and stay on for more than a few months. And many times people will just go straight to methadone due to the price which is something that I strongly discourage. It is addictive and in many ways, you are just substituting one drug for another and the cynic in me thinks that “Big Pharma” likes to keep people on their drugs for as long as they can. Suboxone is a big money-maker for it’s company. As I mentioned, unless you are very well off, you will not be able to afford to take the drug for as long you you might need it.
The side effects are not plentiful but they are very annoying and the constipation is quite exquisite so it’s worth mentioning again. The other side effects again are tolerable but it’s still worth thinking about before you begin Suboxone therapy.
Ultimately, I think Suboxone can be a very good alternative and treatment for those that can afford it and can make sure that they have a plan for getting off of it in a timely fashion. If you can do that and you can handle all of the other things that go with it, Suboxone is a good treatment if you are the right candidate. It’s also worth noting that it’s extremely important that you have a doctor that is committed to helping you stick to your “plan” with an end-game in site. For those people in my neck of the woods, Dr. Earthman is someone that I would highly recommend because he will be able to guide you responsibly and he will honestly assess your condition and whether or not Suboxone is the right treatment for you. You HAVE to find a doctor like him to administer Suboxone or you will risk being on Sub for a long long time. Again, whatever works but just remember that there’s no silver bullet…get educated and know the long-term consequences before taking anything for your opiate addiction. I hope that this has helped you understand Suboxone a little bit better and that you will now be able to weigh the factors involved so that you can come closer to taking that first step. Good luck!
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