Suboxone – An Objective Overview

First, some opening remarks: This page contains most of the basics about Suboxone as well as some pros and cons. Although it may seem like an obsession here, Suboxone keeps coming up. People who are on Suboxone, are considering taking Suboxone or trying to get off Suboxone are literally flooding this site. I can sense the panic in people’s emails and there’s a lot of information flying around out there — some of it sensational and bogus.

All of the following information and opinions are, of course, mine. I have read all of the abstracts, articles, clinical trial data and even the submission for approval to the FDA as well as the final approval letter granting Suboxone marketing rights here in the US. Along with the published data, I have spoken to literally hundreds of Suboxone users, ex users and prescribing physicians. Furthermore, I have personally been on Suboxone. I’m not a doctor or a pharmacist so the technical bits are generalized because people just want to know the basics. Suboxone can be a useful therapy for many people but some people who are on it right now probably should never have gotten on it in the first place. This is my opinion and many people in the clinical and pharma world may not share my views but since this is my site, I’m going to call it like I see it.

Suboxone – What is It?

Suboxone is a combination of Buprenorphine and Naloxone that is prescribed for opiate addiction. It is called a “partial-agonist” opiate because it occupies the opiate receptors in your brain but does not cause acute, narcotic effects. Suboxone tablets come in 2 strengths; 8mg and 2mg. Suboxone is also administered in “strips” that dissolve under the tongue and also come in 2mg and 8mg strengths. In 2014, a drug called Subzolve which is a trans-dermal patch (similar to a nicotine patch) that administers the medication over time.

Suboxone comes in 8mg and 2mg sublingual tablets

Suboxone comes in 8mg and 2mg sublingual tablets

How Does Suboxone (Buprenorphine) Work?

(Click on the image below to read about Suboxone’s mechanism of action)

Suboxone Mechanism of Action

Suboxone Mechanism of Action – Brought to you by the good folks at: The NAABT (National Alliance of Advocates for Buprenorphine Treatment). Sheesh, really? Oh well, it’s a good sell sheet nonetheless.

Who Should Be Taking Suboxone?

In my opinion:

#1. Patients/addicts with a history of long-term, heavy opiate addiction and abuse

#2. People who repeatedly commit drug-related felonies and/or are a danger to society in order to feed their drug habits

As I have written in some recent posts (“To Sub Or Not To Sub” & “Suboxone: Is A Storm Looming?”), I equate Suboxone to a rich-man’s, high-tech methadone since it’s a good replacement therapy for heavy opiate abuse and addiction. From a societal perspective, Suboxone can help reduce drug-related crime, homelessness and overdoses so there are plenty of very worthwhile applications for Suboxone. That’s why the majority of study participants in Suboxone clinical trials are comprised of heroin users and heavy, heavy abusers of potent opiates such as Dilaudid.

This is a very important distinction that is sometimes blurred by marketers and distributors of Suboxone.
Suboxone therapy is for people who simply cannot discontinue their use of heroin or powerful opiates even if they were not faced with the looming specter of withdrawal. It should be considered a long-term (perhaps even life-long) therapy for people whose addictions are so acute that they are literally left with 2 choices: jail or death. These addicts continue to use because they are chronically addicted to the high — not simply afraid of withdrawal. Suboxone’s primary clinical benefit is that it significantly reduces cravings for opiates. It’s effective because it takes away addictive impulses. Many of the visitors to this site that I come in contact with do not necessarily fit that description. They would give their left arm to get off of the pills, yet they are afraid of the WITHDRAWAL. Of course, we have many addicts that visit this site and they might be appropriate candidates for Suboxone; but for those that are physically dependent on opiates, Suboxone should be taken only after understanding all of its benefits and drawbacks.

When Do You Take Suboxone?

When Suboxone occupies your opiate receptors, other opiates cannot have an effect

In order for Suboxone to work, it must occupy EMPTY opiate receptors or you could suffer from precipitated withdrawal. You Do Not Want That

In order for Suboxone to work, the opiate receptors in your brain must be totally free (empty). Opiate receptors free-up when drugs are no longer being delivered to the brain. Your first dose of Suboxone must be taken when your opiate receptors are clear. However, there’s a catch.

This “freeing-up” of the brain’s opiate receptors is what causes withdrawal symptoms. (See the graphic to the left). The red dots in the graphic are the opiate receptors and the yellow-ish dots are “opiates.”  In the graphic to the left, some of these yellow dots are occupying the opiate receptors and stimulating them (the little stars). As the opiate receptors “free-up” they are no longer being stimulated. In order to begin Suboxone therapy, your brain’s opiate receptors must be fully free which means that all consumption of opiates must stop prior to taking the first dose of Suboxone.
In other words, a person who is physically dependent on opiates must not take their first dose of Suboxone until they have stopped their intake and are experiencing full withdrawal symptoms. You can’t park a car in an occupied space.

Suboxone stimulates opiate receptors and blocks other opiates

Suboxone stimulates opiate receptors and blocks other opiates

So How Long Do You Have To Wait and What Happens If You Don’t?
As you may know, the onset of withdrawal is dependent upon the half-life of the drug that has been in your system. Heroin for instance has a short half-life so it will take only about 4-8 hours for opiate receptors to begin to free-up and full withdrawals to take effect. For a person on Hydrocodone which has a longer half-life, acute withdrawal might not start for 24-36 hours. In any case, you basically have to be pretty sick before you take your first dose of Suboxone OR you will go into what is called “precipitated withdrawals.”

Precipitated withdrawals can be caused by taking the Suboxone too early and not letting those opiate receptors clear out, thereby causing withdrawal. You do NOT want this to happen. To make sure that you are in full withdrawal, your prescribing doctor will rate your withdrawal symptoms on a certain scale called the C.O.W.S. (Clinical Opiate Withdrawal Sale). That way, you both can make sure that you avoid precipitated withdrawals.

After your opiate receptors have cleared and you are in full withdrawal, you can then take your first dose of Suboxone. (See graphic above) This will “trick” your opiate receptors into thinking it’s being fed opiates and will also block any other “real” opiates that try to occupy those receptors.

How Do You Take Suboxone? What’s It Like?

Suboxone comes in two forms of “sublingual” pills. Sublingual means “under the tongue.” You place a pill under your tongue and let it dissolve for about 10 minutes. (Sublingual film and generic version of the drug are also currently available).

It tastes a bit like burnt Tang with a sort of bitter orange-peel taste. For me, the taste is not too unpleasant but some people hate it.  It can take up to an hour for you to feel any effects which are very minimal. Contrary to popular belief and marketing claims however, you WILL feel a very mild calming effect when you take your dose and the intensity of this effect can vary from person to person. Some people actually get a bit euphoric when they take their dose (I did) but it is nothing like taking a handful of Hydrocodone and guzzling 3 glasses of wine. Make no mistake however, there’s a reason why people have a hard time reducing their dose and it’s the same reason why we have a hard time reducing or titrating down regular opiates…Suboxone gives many people a little bit of “narcotic nostalgia.” Anybody that says differently is either lying or hasn’t taken it.

Suboxone is taken "Sublingually" which means under the tongue

Suboxone is taken “Sublingually” which means under the tongue..yummm

What Are The Pros and Cons of Suboxone Therapy?

(Note: I go into the pros and cons of Suboxone therapy in detail in my blog post “To Sub Or Not To Sub…Suboxone That Is”)

The Pros 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 intense narcotic effects and provides a stable means to permanently resolve your opiate cravings.
  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 for most people to accomplish due to the fact that it has a very mild narcotic effect so you won’t be tempted to take more.
  5. Provides a way to partially avoid 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.

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 met others that have gotten really, really hooked on it although I’m not sure why; there are more powerful narcotics that provide a much more intense narcotic effect than Suboxone.
  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 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.

“There’s a LOT of Scary Information On The Web About Suboxone. What’s Fact and What’s Fiction?”

As I mentioned in the beginning of this page waaaay up at the top, there have been a lot of things floating around about Suboxone…some true, some totally false. I have tried my best to give you the facts and an honest assessment of Suboxone with its benefits and its shortcomings. The last thing that I want to address is to speak to those of you out there who are on Suboxone and want to get off of it. Candidly, some of my blog posts and articles like this may have unwittingly caused some fear among current users of Suboxone and that was never my intent. So I want to talk a bit about fact v. fiction and also -hopefully- ease some people’s fears about the long-term consequences of being on Suboxone and getting off of it.

Again, I’m not a doctor but I have probably read as much of the clinical literature on Suboxone as most of the clinicians who prescribe it. Sadly, many folks who work in rehabs or detox centers know very little about Suboxone’s long term effects and I’ve seen a lot of people scratching their heads and even telling me, “Oh we only use Suboxone to Detox, we don’t use it long term.” So it appears that there is still a lot left to be learned about this drug. But I’ll tell you what I have read and what I’ve been told by people who should know about getting off Suboxone. First let’s clarify a few things about Suboxone by playing “Fact or Fiction”

Fact or Fiction?

Fact: Suboxone Withdrawals are Milder than Opiate Withdrawals

By and large the withdrawal syndrome and symptoms of Suboxone are milder than full agonist opiate withdrawals. Of course people will tell you that their withdrawals were bad from Suboxone because ANY withdrawal or detox from this type of substance is going to be uncomfortable. Suboxone has a much longer half-life than an opiate so it takes longer for those opiate receptors to free-up therefore the withdrawal period for Suboxone can take longer which obviously makes it seem that much worse. However, there have been huge studies that have been meticulously monitored with patients who have rated their symptoms based on the C.O.W.S. scale and Suboxone had overwhelmingly more mild symptoms than opiate withdrawal. This has been my personal experience as well.

Fiction: Suboxone Withdrawals Last Forever and Can Do Permanent Damage to People’s Brains

As I mention above, Suboxone has a much longer half-life than a regular opiate so it takes longer for your opiate receptors to clear out which results in a longer withdrawal period. Yes, it is true that Suboxone withdrawals can last quite a bit longer than opiate withdrawals. However, I am not aware of any studies or evidence that suggest that Suboxone causes permanent psychological damage to the brain or any other part of the body due to long-term use.

The studies conducted on Suboxone have been randomized and well designed. That is why pharmaceutical drug manufacturers must spend millions of dollars and years of development to market a drug. Based on the level of scrutiny that a drug like Suboxone would undergo in order to be approved, it just doesn’t make any sense that Suboxone would have the capacity to cause permanent harm or damage to the brain. Eventually after stopping Suboxone, your brain chemistry will return to normal; it may take a few weeks or possibly a month or two but you WILL get back to normal. Suboxone does not make people permanently, psychologically impaired. You will NOT go bonkers!

Fact: P.A.W.S. Is Real But Not As Bad As Many People Say It Is

P.A.W.S. (Post Acute Withdrawal Syndrome) is a real syndrome that sometimes affects people coming off of ANY type of opiate but seems to happen more frequently in people that have been on Suboxone for over a year or so. This may be due to the longer half-life or some other aspect of Suboxone’s chemical make-up and is one of my biggest beefs about people who initially marketed and prescribed Suboxone. P.A.W.S. can happen and it does happen to people who have been on Suboxone for a long period of time. I have had many, many people here use Withdrawal-Ease for  up to several months for their P.A.W.S. symptoms (which include, lethargy, insomnia, depression etc.). Many of those people have told me that Withdrawal-Ease does help them a lot and eventually their symptoms do go away (due to the body’s natural detox process) and they stop needing it. Bottom line: P.A.W.S. may feel like it lasts forever but I have not heard of anyone having it for more than a couple of months. Are there exceptions? Sure but in my experience, P.A.W.S. lasts about a month and then goes away for the majority of people.

Fiction: Once You are On Suboxone for a Year or So, You Can Never Get Off

Not true. What IS true is that Suboxone is very difficult to get off of because the extended withdrawal period and P.A.W.S. This is my second beef that is related to my first beef above. The marketers of Suboxone have said to people, “Hey Mr. Vicodin Addict, would you like a painless way to get off of your opiates? Well try Suboxone! You won’t have any withdrawals and then it’s just any easy taper with minimal withdrawals and you’re done!” Well obviously that is not the case and what many people have experienced is that they traded one drug with a pretty bad withdrawal for another drug that has a less acute withdrawal but is made a lot worse by the fact that it’s a lot longer. Did the makers of Suboxone know that all of these people would have a hard time getting off of their terrifically expensive drug?

Getting off of Suboxone is very possible but if you ask many of the current users of Suboxone, they’d take a 5 day Vicodin withdrawal ANY DAY compared to what they are facing now. The fact of the matter is that the makers of Suboxone should have narrowed the indications to people who are chronic drug users; people who will die or end up in jail unless they get off drugs. These people really should be on Suboxone for the rest of their lives. The marketing guy in me has to think that if you look at “Population A: Heroin Addicts, criminals etc etc.” and then you look at “Population B: People who got physically dependent on opiates due to a surgery or by getting pills from a friend”… by adding “Population B” to the indications for the drug you turn a 100 million dollar drug into a billion dollar drug right? I know I’m cynical. I think I got off track. You CAN get off Suboxone; it’s just harder to do so than your original drug of choice unfortunately.

I’ve Been On Suboxone For a While and Want To Get Off. So What Do I Do Now?

Let me just say that there are many people in the addiction community that don’t have a very solid answer for this question. I’ve heard a lot of different theories and I will share them with you but here’s the deal: I’m not a doctor and I’m not YOUR doctor. So if you try any of this stuff, you do so at your own risk or more preferably with your prescribing physician so that he or she can monitor your progress. If you do not work with your doctor on this you could harm yourself or even die. I’m could not be more serious about this.

Suboxone Detox Option #1: “The Glacial Taper Process”: Read: How To Detox From Suboxone

The “Standard of Care” for Suboxone detox is to slowly taper over a long period of time. When I say long I mean 6 months or possibly more. You and your doctor can figure out how to titrate your dose but the key here is to have a disciplined taper that does not cause withdrawal symptoms. I’ve heard of people even cutting their 2mg pills with razor blades to get to the lowest possible dose before finally quitting. This will give you an idea of the increments that you will be looking to titrate at as you detox. Your doctor can also prescribe some other medications if you have any symptoms but frankly I think Withdrawal-Ease does a better job. Approximately 25% of my customers are Suboxone patients and I have heard great things about their experiences with the product. Of course I want you to try Withdrawal-Ease but I also think it’s the best way to detox and the best option for P.A.W.S. symptoms. Your doctor may give you some helpful medicine but a nutritional supplement is also a good idea. For now, I believe that this is still the best way to detox from Suboxone.

Suboxone Detox Option#2 (Experimental): “Go back to What Brung Ya”

I have heard from a couple of doctors and a few customers that they believe the easiest way to detox is really to start all over and start taking a full-agonist opiate of some sort. Most people have tried Vicodin, Lortab and other Hydrocodone variants. The people that I have talked to have sworn by it. Essentially what they did was to wait for approximately a week so that their opiate receptors are free of Suboxone and then they began low doses of opiates. They would stay on the opiates for a month and then go through withdrawal cold-turkey. It makes sense I suppose but there are a few things that concern me about this. Obviously, there’s a serious risk of overdose if you start taking opiates and the Suboxone is still in your system. Secondly, you’re back to square one with your drugs and this whole exercise has been a waste of time and money. Thirdly, are you just going to go back and start using again?

If you consider this option, you MUST do so under the supervision of a doctor. There is a real risk of overdose because of the Suboxone in your system and your tolerance has lowered considerably since you last took opiates. You need to have a disciplined plan to initiate the opiates as well as taper off of them and detox. I do not recommend this option unless you have a doctor who is participating fully in this plan.

Suboxone Detox Option (Experimental) #3: “Suboxone Overload

This last option is the most far fetched because I’ve only heard it mumbled by a couple of doctors and read a couple things about it. To tell you the truth I’m not sure if I even believe it. But here it is anyways. Some people are saying that there has been some recent success with bringing a patient’s Suboxone dose up very high for a short period of time and then cutting it off completely. I don’t know how this would work chemically and I’m really hesitant to even post it here because in my opinion it doesn’t make sense. We’ll have to wait and see but I do hope that they come up with something that can help shorten the duration of the withdrawals from this stuff. For now, please don’t try this. You can ask your doctor to look into it and you’ll probably receive a blank stare.

This third option is theoretical…don’t even think about trying it unless you see your doctor first!

Well there you have it folks. Suboxone. The “Miracle Drug” that’s really not so miraculous. As I mentioned in the beginning, Suboxone has its place in addiction medicine but it is far too over prescribed for my taste and now we have a whole population of people who are desperate to get off of Suboxone. Many of these people were never told that Suboxone would give them prolonged withdrawals and they were never really informed about the costs and long-term implications of taking this drug. I put the blame directly on the marketers of the drug and partially on the doctors who now have a consistent patient base for their practices. Suboxone is NOT a miracle drug and I’m still waiting for someone to explain to me why Suboxone is any different than Methadone when it comes to clinical outcomes in the treatment of opiate addiction. It’s helped a LOT of people but I guarantee you it’s also screwed a lot more people that thought they were getting an easy way out of their opiate dependency but just got an easy way into another one.