Is using Suboxone recreationally a serious concern? Is abusing Suboxone possible?

Ever since congress approved buprenorphine for use as a treatment for opioid addiction, authorities have been concerned about abuse. After all, buprenorphine is an opioid, so of course they found it difficult to accept Subutex or Suboxone treatment for opioid use disorder. For nearly two decades, lawmakers and law enforcement officials believed that rogue doctors might recklessly prescribe buprenorphine-based drugs to opioid-addicted patients.

Experts worried that there would be a new wave of pill mills, fueled by buprenorphine addiction. Fortunately, their fears of Suboxone addicts shooting up to stave off Suboxone withdrawal have not been realized. While the opioid epidemic and opioid crisis continue to ravage our country, with imported fentanyl from China and Mexico causing increasing opioid overdoses, there has never been a Suboxone overdose crisis caused by addicts shooting, snorting, or smoking Suboxone.

Still, because of fears of rampant buprenorphine abuse in the early days, the pharmaceutical industry responded with a solution: add naloxone to buprenorphine to stop patients from shooting it up. Suboxone is a combination of buprenorphine and naloxone, and it has become the standard for heroin addiction treatment and fentanyl addiction treatment.

The authorities, including lawmakers, law enforcement, and healthcare administrators, loved the idea. If a Suboxone patient attempted to shoot their meds into a vein, the naloxone would make them sick from immediate withdrawal symptoms. Problem solved.

Yet, there were several issues with this approach. First, there was no solid evidence that adding the opioid blocker naloxone to an opioid, such as buprenorphine, slows down Suboxone abuse or prevent Suboxone addiction.

The other issue was that no one was certain if there was a significant amount of buprenorphine abuse or recreational use. While it made sense to addiction treatment experts, as well as law enforcement and government authorities, that buprenorphine being an opioid would have abuse potential, studies of buprenorphine diversion revealed that little, if any, abuse was happening.

Buprenorphine is the broccoli of opioids.

Have you ever tried to convince young children to eat their broccoli? Most will shake their heads and cover their mouths. The little tree-like vegetables have a reputation for being good for you and not tasting great.

But, you may know the occasional child who enjoys steamed broccoli, soaked in sauce. For this argument, let’s say we are talking about raw broccoli with no sauce or dressing. It is clearly edible, but there are few fans of raw broccoli.

Now, suppose you were able to find the very rare child who does not mind crunching on a few pieces of raw broccoli without dressing. Would you be concerned if you left a large plate out, that the child would binge, eating so much broccoli that they got sick?

When you imagine this scene, you realize how preposterous it would be. Almost no one on the planet is at risk for binging on broccoli. It is just not that kind of food.

Now, let us consider buprenorphine as an opioid compared to broccoli as food. While buprenorphine is, by definition, an opioid, it has a fairly low abuse potential, due to its unique nature.

Buprenorphine has a ceiling effect, meaning the effects of the drug do not increase above a certain level. This prevents users from taking more and more of the drug to get high.

The reason for the buprenorphine ceiling property is this: buprenorphine is both a partial activator of the opioid receptor (a partial opioid agonist), and a blocker (an opioid antagonist) at the same time. Alternatively, most opioids activate the receptor fully without blocking.

The unique shape and properties of the buprenorphine molecule make it ideal as an addiction treatment medication. While abuse is possible in theory, it is not likely.

Of course, if I was very hungry, and the only food available was broccoli, I might stuff myself with the green vegetable, simply out of habit. Similarly, some opioid users may try shooting Suboxone out of habit, when no other opioid is available.

While we can debate and theorize endlessly over the risk of buprenorphine abuse, and recreational Suboxone use, the best answers will come from real world data. In recent years, multiple studies have been performed to look at street use of Suboxone, as opposed to use in drug addiction treatment programs.

It is true that Suboxone is diverted and sold on the streets. The films are individually wrapped and easily identifiable.

What happens to Suboxone sold on the streets by drug dealers?

The question is, what are drug users on the streets using Suboxone for? Antibiotics are also sold on the streets, but we know that people are not getting high on them.

In study after study, the results have been consistent. At least 90% of Suboxone on the streets is used to self-treat opioid addiction and physical dependence.

Drug users who want to stop heroin or fentanyl, but they do not want to enter the system, by going to a clinic, obtain Suboxone, so they can quit dangerous street opioids without getting sick. Are they getting high while on Suboxone?

No, they simply do not want to suffer days of opioid withdrawal and opioid craving. If people on the streets are not using Suboxone to get high, then would it be a good idea to make Suboxone over-the-counter, like naloxone? Should buprenorphine be given out freely to heroin addicts and fentanyl addicts?

At this point, in the US, our approach is that we want sick people to see a doctor. We do not want people self-treating for dangerous medical conditions.

Could over-the-counter Suboxone ever become a reality?

Yet, it is possible that over-the-counter Suboxone could become a reality in coming years. As authorities become more comfortable with the fact that there is very little risk of wide scale abuse of the drug, they may become more open to the idea.

While studies indicate that Suboxone on the streets is overwhelmingly not used as a drug of abuse, to get high, there are still people who insist that Suboxone is being abused. They often talk about Suboxone abuse in prisons, and how opioid naive individuals can get a heroin-like high from the drug.

Of course, if an opioid user has Suboxone and no other opioid available, they may attempt to abuse it by shooting it up into a vein. Clearly, based on the way buprenorphine interacts with opioid receptors, the high, if there is any high, will not be anything like heroin.

In fact, there have been many reports of opioid naive people trying to use buprenorphine recreationally, only to discover that even the smallest amount makes them feel very ill. They get nauseous and sometimes vomit after using just a tiny fraction of a Suboxone film or tablet.

If an opioid naive person was to experience a mild euphoric feeling with buprenorphine, the experience would be short-lived. That person would quickly develop a tolerance to the effects of low-dose buprenorphine, and within a very short time, they would no longer get any kind of high feeling from the drug.

Why do we still have a Suboxone stigma?

At some point, we must address the issue of why we, as a society, obsess over the remote possibility that a few people might get a temporary mild high from Suboxone. How important is it to restrict access to this life-saving drug, based on this concern?

Does the partial opioid agonist nature of buprenorphine justify the dirty looks that pharmacists give their Suboxone patients? Is it right that doctors are terrified of oppressive oversight and possible discipline if they write prescriptions for Suboxone?

There are products on the shelves of grocery stores that are far more intoxicating than Suboxone. In the middle of an opioid epidemic, states were more obsessed with legalizing cannabis than making buprenorphine more accessible to the people whose lives are at risk every day from opioid overdose.

Is it possible to binge on broccoli? Sure. I have enjoyed a large plate of seasoned, steamed broccoli, and I probably could have had another plate.

Yet, was I at risk for becoming morbidly obese from broccoli consumption? Almost certainly not.

Suboxone does have some abuse potential, but the benefits far outweigh the risks. The risk of widespread abuse of buprenorphine is minimal, but the benefits of increased access for people with opioid use disorder are significant.