Is Suboxone addictive, or is it just trading one addiction for another?
Is Suboxone addictive? The honest answer is that Suboxone causes physical dependence in nearly everyone who takes it daily for more than a few weeks, and it causes addiction in very few people. Those are two different conditions, and most of the argument about Suboxone comes from confusing them. Physical dependence is not addiction.
Suboxone is the brand name for a film that contains two drugs, buprenorphine and naloxone. Buprenorphine is an opioid that partly activates the opioid receptor while blocking it at the same time, and naloxone is an opioid blocker that was added to discourage people from injecting the medication. When I say Suboxone here, I mean any of the buprenorphine medications used to treat opioid addiction, including ZubSolv and the generic films and tablets.
Since the day buprenorphine was approved for treating opioid addiction, the same objection has followed it around. Is it not just another opioid? Are Suboxone patients trading heroin or fentanyl for a legal habit they can never quit? Is a Suboxone doctor a drug dealer with a medical license?
While Suboxone is an opioid with real risks, the claim that a patient on buprenorphine has simply swapped one addiction for another confuses two conditions that could not be more different. So, what is the difference between being dependent on a drug and being addicted to it?
Withdrawal when you stop a drug does not make that drug addictive.
Some drugs are habit forming and carry a real potential for misuse. Other drugs are not addictive at all, but they still cause physical dependence, and when you stop taking them abruptly, you get sick. That sickness is withdrawal, and it is not the same thing as addiction.
In fact, a great many medications cause withdrawal when they are stopped. Blood pressure medications, antidepressants, and anti-anxiety medications can all make a person quite ill when they are stopped suddenly, and no one accuses a heart patient of being addicted to their beta blocker. Buprenorphine belongs in that category of drug.
Unfortunately, some so-called “experts” in the addiction treatment business make an association between withdrawal and addiction, and then they use it as an argument. If stopping Suboxone makes you sick, they say, then Suboxone must be addictive, so you should get off of it as soon as possible, or never start it at all. It is a fallacy, and it pushes people off of life-saving treatment too early.
Physical dependence means that your body has adapted to a drug and will protest when the drug is taken away. Addiction is a pattern of behavior, with obsession, loss of control, and continued use in spite of harm.
A person who gets sick when they stop a drug has a chemistry problem. A person who cannot stop using a drug that is destroying their life has an addiction problem.
How can you tell the difference? Watch what happens to the patient.
The best way to see that Suboxone is not typically addictive is to watch what happens to patients during Suboxone treatment. Before starting, a person who is addicted to opioids obsesses over their drug, uses to excess, harms themselves repeatedly, and cannot stop. Then, on buprenorphine, the obsession stops.
Patients often describe the same thing in the first weeks: they stop harming themselves, they stop thinking about opioids all day, and, in a short time, their life returns to something like normal. Work, sleep, and family come back. That is not what an addictive drug does to a person.
A patient who is stable on buprenorphine is not “still using.” They are in recovery, and a rehab counselor or a relative who says otherwise is measuring recovery with the wrong yardstick. While therapy and peer support can help a great deal, and I refer patients who want them, the medication does its work whether or not you ever sit in a group.
So, is Suboxone completely without risk? No, and it would be dishonest to say so. The only medical treatment with no downside is a placebo, and a placebo does nothing at all.
Why does buprenorphine have such low addictive potential?
Buprenorphine is unique among opioids for how it works at the receptor. According to the Suboxone prescribing information, it is a partial agonist at the mu opioid receptor and an antagonist, or blocker, at the kappa opioid receptor. In plain terms, it turns the receptor partway on, and then it holds on and does not let go.
Most opioids activate the receptor fully and bounce on and off of it. More heroin or more fentanyl means more effect, right up to the point where breathing stops. Buprenorphine has a ceiling.
Its opioid effects are limited by a ceiling effect, so that above a certain dose, taking more does not produce more. Its affinity for the receptor is also much higher than that of fentanyl, heroin, or oxycodone, so it sits there for a long time. The label gives a half-life of 24 to 42 hours. A drug that plateaus and then lingers is a poor tool for chasing a high.
To be clear, physical dependence does develop with buprenorphine, and the label says so plainly. Tolerance develops as well, as it does with any opioid. The low addiction liability does not come from an absence of dependence. It comes from the ceiling and from partial activation.
Because buprenorphine blocks the kappa receptor, it has been studied as a possible antidepressant, and you may read that it helps with anxiety and mood. That remains a research idea, since no buprenorphine product has been approved by the FDA for depression, and a drug that causes physical dependence is unlikely to be prescribed for anything other than opioid addiction or chronic pain.
Buprenorphine is the broccoli of opioids.
Have you ever tried to convince a young child to eat broccoli? Most will shake their heads and cover their mouths, and the few who will eat it want it steamed and drowned in cheese sauce. Now, imagine the rare child who does not mind crunching on a few pieces of raw broccoli with nothing on it.
Would you worry, if you left a large plate out, that the child would binge on it until they were sick? The idea is preposterous. Almost no one on the planet is at risk of binging on broccoli. It is edible, and some people even like it, but it is not that kind of food.
While this is not a perfect analogy, buprenorphine is the broccoli of opioids. It is, by definition, an opioid, and a very hungry person might eat a whole plate of broccoli out of habit, just as some people who use opioids will try Suboxone when nothing else is available. Yet, the ceiling effect and the naloxone make it a poor choice for getting high, and injecting Suboxone is likely to bring on withdrawal in a person who is dependent on a full agonist such as heroin or methadone.
A person who has never taken opioids and tries buprenorphine to get high usually gets sick rather than high, and even a small dose can be deadly to someone who is not used to opioids. That is one more reason it is a prescription and not a party drug. It works very well for treating opioid addiction, and it works very poorly as a drug for getting high.
Where did the story that Suboxone is just another addiction come from?
Office-based buprenorphine treatment began with the Drug Addiction Treatment Act of 2000, which allowed doctors to treat opioid addiction with buprenorphine from an ordinary medical office rather than a methadone clinic, and the FDA approved Subutex and Suboxone in 2002. From the very beginning, authorities worried about misuse. After all, it was an opioid, and methadone, the other opioid used for this purpose, activates the receptor fully and behaves much more like the opioids people misuse.
Subutex, the original brand, contained buprenorphine alone. Suboxone added naloxone as a deterrent, and lawmakers, law enforcement, and healthcare administrators loved the idea. If a patient injected the medication, the naloxone would make them sick. Problem solved.
Yet, no one had established that there was a significant amount of buprenorphine misuse to deter. What existed instead was lore: stories of Subutex tablets dissolved and injected in dark alleys, and of Suboxone films smuggled into prisons under postage stamps and inside book bindings. The manufacturer, which has always fought hard to protect its patents and its prices, was happy to lecture law enforcement about diversion in a way that favored its own products.
Law enforcement lore, patent politics, and a pharmaceutical sales pitch are not evidence. They are a story, and it was repeated often enough that it became common knowledge.
What is diverted Suboxone actually used for?
Suboxone is sold on the streets. The films are individually wrapped and easy to identify, and there is no point in pretending that diversion does not happen. The question is what people are buying it for.
What is observed, over and over, is that people who buy Suboxone from a dealer are overwhelmingly using it to treat themselves. They want to stop fentanyl or heroin without getting sick, and they do not want to enter the system to do it. Antibiotics are sold on the streets, too, and no one imagines that people are getting high on them.
If someone is buying Suboxone illegally to treat their own addiction, why not simply see a doctor? Unfortunately, our government at every level has not been supportive of making the medication available to the people who need it. Many doctors still refuse to prescribe it, some states have warned that Suboxone clinics are the next wave of pill mills, and some pharmacists give their Suboxone patients dirty looks at the counter.
Narcotics Anonymous and Alcoholics Anonymous groups have slowed access as well, by telling meeting attendees that they are not “clean” if they take Suboxone. That is their word and their definition, and it is not one I use for a person.
Some people value the fellowship of a meeting, and that is their choice to make. I no longer recommend meetings as part of medical care. They are not professionally moderated, members are encouraged to share private health information with strangers, and NA’s own position discourages the medical treatment that works. Whatever you decide, the room stays out of your medical care.
Can you get addicted to Suboxone? How long does it take?
This is a question people type into Google, and it is the wrong question. Anyone who takes buprenorphine every day will become physically dependent on it within a few weeks. That is true of every patient, and the prescribing information says so plainly: chronic administration produces physical dependence, with withdrawal upon abrupt discontinuation or a rapid taper.
Addiction is not on a timeline. It is a pattern of behavior, and a person either develops it or does not. You cannot count the days until a patient who takes their medication as prescribed and gets on with their life becomes addicted, because that patient is not headed there.
Where addiction risk does exist, it attaches to illicit or recreational use, not to supervised treatment. While misusing any opioid can end in addiction, a person who has never had an opioid problem and takes buprenorphine to get high is in a very different situation from a patient with opioid addiction who is prescribed buprenorphine to treat it.
Prescribed buprenorphine treats opioid addiction. It does not cause it. The withdrawal you would feel if you stopped is evidence of Suboxone dependence, and dependence is what we expect.
Suboxone is a real medicine with real risks.
It is easy to attack any medical treatment as dangerous. Any treatment that actually works has a downside, which is why we have side effects, adverse reactions, and treatment failures. Suboxone is not a placebo, and it should be prescribed with care.
The everyday side effects are familiar to most patients: constipation, sweating, fatigue, insomnia, and, for some, nausea or headache. The serious risk is respiratory depression, and the prescribing information warns specifically about the danger of taking benzodiazepines, alcohol, or other sedatives while on Suboxone. That combination is the one that kills, and it deserves more attention than it gets.
Yet, the honest comparison is not Suboxone against an imagined drug-free life. It is Suboxone against street fentanyl and heroin, which kill people every day. Willpower, tough love, residential treatment, and 12-step meetings alone have been tried, over and over, and the deaths continued.
So, before you tell someone that Suboxone is just as bad as heroin, please think carefully about what you are saying. A relapse on today’s street supply all too often kills a person before they get the chance to be ready for help. Suboxone keeps them alive long enough to get there.
Can you stop taking Suboxone? Yes, when you are ready, and slowly.
There is no rule that says a patient must ever stop. The prescribing information states that there is no maximum recommended duration of maintenance treatment and that patients may require treatment indefinitely, for as long as they benefit. Whether and when to taper is a decision between you and your doctor. Many doctors, myself included, think at least a year of stability is reasonable before coming off the medication is seriously considered, though a taper can begin within the first year when it is tolerated.
When you and your doctor agree that you are ready, the taper should be gradual, and the final dose before stopping should be as low as possible. I believe the same high receptor affinity that makes buprenorphine safe is what makes the last milligrams the hardest to give up, so the reductions get smaller as the dose gets lower, sometimes down to a small fraction of one milligram, or to dosing every other day. Some patients are ready to move faster than others, and it is your doctor’s job to keep the pace matched to you, never to a calendar.
What about withdrawal after the last dose? Buprenorphine withdrawal is typically milder than withdrawal from a full agonist, and it is often slow to arrive, which fits what patients describe.
In my experience, the worst of it does not pass in a few days, as I once wrote myself, but runs for a week or several, and it can take a bit longer to feel fully normal. There are non-addictive comfort medications that can help with that stretch, and you should not have to go through it alone.
Quitting cold turkey is a different matter, and I have written separately about what happens if you quit Suboxone cold turkey and about the best way to get off of Suboxone for good. Abrupt discontinuation brings on withdrawal, and the real danger after stopping is relapse. A relapse on today’s street supply can be fatal, so if you or someone you love has relapsed and is in danger, call 911.
Quitting Suboxone is not always easy, but it is always possible, and it is always your decision. As more doctors discover that the addictive potential of buprenorphine is low and that its benefits are large, the undeserved reputation is slowly wearing off. You do not have to wait for it to finish wearing off to get well.
Dr. Leeds treats opioid dependence with buprenorphine (Suboxone, ZubSolv, and their generic films and tablets) by telemedicine for patients throughout Florida, with in-office visits available in Fort Lauderdale. New patients start at home with phone support, using a low-dose start when fentanyl is involved, and there are no mandatory meetings, no required counseling, and no taper imposed on a schedule: patients direct the pace of their own care, whether that means long-term maintenance or a gradual taper to a very low final dose. Details are on the Suboxone treatment page, and to schedule a consultation, contact Dr. Leeds.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
