Suboxone: To Sub Or Not To Sub…

Thinking About Taking Suboxone?

If you are struggling with opiate dependency (like I was), you’ve probably conducted some research on your treatment options: taking Suboxone is one of those options. I wouldn’t blame you if you thought that taking Suboxone sounds like a pretty “easy fix” compared to the alternatives. As I’ve mentioned, throughout the site, I had a physical dependency to opiates and my main concern was getting through the detox as comfortably as possible.

NOTE: For those who are profoundly addicted to pills or shooting heroin (or both), rehab should always be a consideration and remains the gold-standard. 

Rehab is very expensive ($30,000 for 30 days… and up), requires at least 30 days. In my case, I truly felt like that level of therapy was unnecessary; even if I had the time or money to do it. Although I must admit, some of the new rehabs look fantastic! You know, the ones that are perched on a cliff and have 4 pools along with personal chefs, yoga, exercise rooms, horseback riding…awesome. It almost makes you forget that you’re going to be miserable most of the time. But, I suppose I’d rather be miserable in a high-end rehab than almost anywhere else. Kind of sickening.

Then, for a mere $10,000 you have Rapid Detox, which sounds like some sort of Inquisition-era torture. They put you under general anesthesia for 12 hours and then make your body go through a procedure that is not fully understood or proven. They use drugs like Narcan to empty your opiate receptors and essentially detox your body at light-speed. It sounds straightforward but there’s something very draconian about it…no thanks.

Next up is the acute care (hospital) “In-patient Detox.” At an in-patient detox, you just sit in a bed, take Xanax and Advil for 7 days; after which they hand you a $6,000 bill when -in reality- they should pay you.

And finally, there is Suboxone (a combination of Buprenorphine and Naloxone) which you take instead of your opiate of choice for a few weeks and then gradually taper off (or so the theory goes). The slang for Suboxone is “Sub”…it is often referred to as the “rich man’s methadone”.

Partial Agonist v. Full Agonist:

It’s 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 neurotransmitters to release dopamine and serotonin 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 those receptors slightly different instructions on what chemicals and processes to release. Suboxone is not supposed to produce any narcotic effects and is a deterrent to other opiates. That’s all you need to know right now…read on.

Lesson Recap: Vicodin = “Full Opioid Agonist”    Suboxone = “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 but it does not produce the same “high” as pain killers. Thus, Suboxone is a very powerful opiate 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 brain as a bunch of tiny locks. You can’t occupy 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. So, if you are taking Suboxone, Vicodin won’t work very well. In fact, if you are taking Suboxone and you decide it would be a good idea to pop a couple Lortab, you’ll be in for the surprise of your life.

How Do You Take Suboxone:

Suboxone is usually administered sublingually which means that it dissolves under your tongue. There are also trans-dermal patches available but the sublingual strips and tablets are the most popular way of administering the drug. The tablets and strips come in two different strengths (2mg and 8mg). I’ve never tasted the strip so I cannot give you a first hand account but I have tasted the tablets. The tabs aren’t too bad; sort of like eating a burned orange peel or a bad batch of Tang. Yum. Some people can’t stand the taste but I think it’s tolerable. As of June 2016, an implantable, continuous release form of buprenorphine has cleared the FDA for those that wish to take Suboxone for an extended period of time.

When Do You Take Suboxone:

Here’s the kicker. Let’s assume you are on 8 Norco 10/325’s per day and all of those opiate receptors in your brain are occupied. In order for Suboxone to work, your 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 discontinue their use of opiates (in this case the Norco) until those receptors become “receptive”.

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 16-24 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. Remember that “surprise of your life” that I talked about earlier? 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. Typically, one has to wait at least 24 hours before taking their first dose of Sub. Taking suboxone and another opiate like hydrocodone is never, ever a good thing.

What Can You Expect When Taking Suboxone?:

After your first dose, it doesn’t take long for you to start feeling much, much better from the withdrawal symptoms that you’ve likely had to endure for a few hours. At first, Suboxone might make you pretty drowsy and woozy; that goes away. Your doctor might start you off at a pretty high dose (16-32 mg’s) depending on your prior opiate intake. If your doctor plans on immediately weaning you off of Suboxone, they will gradually lower your dose over a period of roughly 2-4 weeks to make sure that you do not have any acute withdrawal symptoms. Your doctor may also decide to put you on a “maintenance dose” in order to prevent relapse or stabilize you for a longer period of time.

Overall, taking Suboxone it does not feel like much of anything; it’s a non-event. You might get a mild “rush” for a few minutes after taking it but that’s about it. Suboxone also does a pretty good job of suppressing cravings for opiates.

If you are on a maintenance dose of Suboxone there’s a very important disclaimer that I must mention. Remember that Suboxone is an opiate; a very powerful one actually. If you stop taking the Suboxone, you will go into withdrawal in much the same way that you would with any other opiates. Suboxone has a longer half-life than a drug like hydrocodone so it will take longer for your withdrawal symptoms to begin but they will happen if you stop taking it.

How Long Do You Take Suboxone?:

By and large, Suboxone can be prescribed for either a detox of 2-4 weeks or your doctor may decide that it is best for you to take it on a longer term basis (a.k.a. “maintenance dose”).

If your doctor decides to prescribe Suboxone in order to help you detox, it’s a pretty simple process. They will have you discontinue whatever opiate you are currently taking until you are in full withdrawal. Once you are sufficiently miserable (in withdrawal) they will administer the Suboxone. Your doctor will stabilize your dose for about a week and then quickly begin tapering you down over a period of 2-4 weeks. This is typical for someone who might be dependent but does not have much of a risk of relapse. For the most part, Suboxone does a good job in this regard however, you may still feel some post acute withdrawal symptoms even after you have discontinued it. Once tapered off, it is up to you to address any cravings you may have with either group therapy and/or counseling.

For those who have more acute addictions and therefore a higher risk of relapse, some clinicians believe that it is best to be on Suboxone long enough so that you don’t immediately fall back into the same pattern of drug abuse. This makes sense to me. If you take Suboxone for 6-12 months, all of those previous triggers and addictive behaviors may have time to fade away. Hopefully this will help you establish a new “lifestyle” and schedule. There are also those who remain on Suboxone in order to control chronic pain although I’m personally not a fan of Suboxone for chronic pain.

I have met people who have been taking Suboxone for years and years as well as people that just took it to detox; it’s really just a matter of what is best for you. By and large, the best of all possible outcomes is to take suboxone for the shortest amount of time possible without putting yourself in jeopardy of relapse.

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 powerful narcotic effects and provides a stable means to quit your opiate addiction or dependency.

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 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 200 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 “nostalgic opiate euphoric” effect. This is my personal experience and others may disagree but I got a little bit of a high from it. Some people abuse Suboxone and can develop quite dependency on it. For the life of me, I have no clue as to why because -as I mentioned- any narcotic effects are weak at best and it’s expensive. I’ve heard of those who have managed to counteract some of the abuse deterrent capabilities of Suboxone and are able to inject it which I would assume produces the desired effect. You can find out about that on your own!

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. With a maintenance dose, 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 (12 years or so), 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.

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 so whatever you weigh 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 just 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 reflect my personal experience with Suboxone. I have also spoken with hundreds and hundreds of people who have taken Suboxone in one form or another. 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 possible. 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 but does not do a good job controlling chronic pain. Besides, if I need opiates for cancer pain or chronic pain, I’d like the narcotic effects please and thank you very much!

*The price of Suboxone makes it very hard for the average Joe to get on and stay on the medicine for more than a few months. Many folks will just go straight to methadone due to the price which is something that I strongly discourage. Suboxone is a big money-maker and it is only going to get more profitable as they recoup R&D costs. 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 to determine if 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 or dependency. Sometimes the cure is worse than the disease. I hope that this has provided you with an adequate introduction to Suboxone. Hopefully this will help you weigh the factors involved so that you can come closer to taking that first step. Good luck!

-George

If this article was interesting to you, you may find the following articles useful as well:

Suboxone…Is a Storm Looming?

How To Detox From Suboxone At Home

Author’s note: This article was written in 2009 so insurance coverage and recent developments of generic forms have reduced the costs.

Updated Jan, 2016