Does Suboxone cause depression?
In most cases, it does not. For many patients, depression gets better after starting Suboxone. While it may not go away completely, it will likely improve.
Suboxone is a film that dissolves under the tongue, and its main ingredient is buprenorphine. When I say Suboxone here, I mean all of the buprenorphine medications used to treat opioid dependence, including ZubSolv and the generic films and tablets.
Yet, the question is a fair one. Some patients feel flat or tired after they start, and family members sometimes say that their loved one seems like a different person. And, there is one situation where Suboxone really can lead to depression, which is after a patient stops taking it.
Physical dependence on opioids is different from addiction.
Using opioids can be depressing, even though, in the beginning, they solve a problem. If you were prescribed opioids for pain, you may have been happy to find something that made your pain more tolerable.
While most patients who take opioids long enough will develop a physical dependence, only some will go on to develop an addiction. Physical dependence means that if you stop taking opioids, you will get physically sick. A patient with physical dependence and no addiction functions normally when taking the medication as prescribed.
Addiction is something else. It is an ongoing obsession with the drug, and a compulsion to take it even when you know that it is causing you harm. Opioid addiction is a severe form of psychological dependence, and it can be life threatening.
Buprenorphine is technically an opioid, and the Suboxone prescribing information says plainly that it causes physical dependence too. The medication guide that comes with every prescription adds a sentence that is worth reading twice. “Physical dependence is not the same as drug addiction.”
That distinction matters most at the end of treatment, and there is a separate article on whether Suboxone is addictive.
How does opioid addiction affect your mood and mental health?
Opioid addiction is depressing because it hijacks the reward center of your brain and traps you in your own mind. You know that you are hurting yourself and the people you love, but you cannot stop.
In the beginning, before addiction, opioids may have been emotionally uplifting for you. Now, caught in the endless cycle of active addiction, you are likely depressed about your situation. And, the depression makes the next dose harder to refuse.
Addiction and depression feed each other this way, and the same is true with alcohol and other drugs. Both deserve attention, and treating one does not automatically take care of the other.
When you start Suboxone treatment, you are able to function normally again, and the constant obsessions and compulsions fade away. For the first time in a long time, you can have hope for the future.
It makes sense that a positive move forward in your life would help you to feel less depressed. Is that the whole explanation? Interestingly, it may not be.
What is the kappa receptor, and what does it have to do with depression?
We often imagine that opioid receptors are all the same. An opioid travels to the brain, binds to a receptor, and causes its effects. This is an oversimplification, because there are several different kinds of opioid receptor.
The one that most people have heard of is the mu receptor. A drug that turns a receptor on is known as an agonist, and a drug that blocks a receptor is an antagonist. Heroin, fentanyl, and oxycodone are full agonists at the mu receptor, which is where the pain relief and the high come from.
While the mu receptor gets most of the attention, the kappa receptor is where things get interesting when it comes to depression. Turning on the kappa receptor does not cause a high. It tends to cause the opposite, a low and uneasy mood known as dysphoria.
Buprenorphine is a very unusual medication. According to the Suboxone prescribing information, it is a partial agonist at the mu receptor and an antagonist at the kappa receptor, which means that it turns the first one on part of the way and blocks the second.
So, in theory, a drug that blocks the kappa receptor could lift a person’s mood. If Suboxone helps with your depression, it may be due to more than the relief of escaping addiction. I believe that the kappa receptor may be part of the reason, although this has not been proven.
Does that make Suboxone an antidepressant?
No. Suboxone is approved to treat opioid dependence, and that is the only use on its label. It is not an approved treatment for depression.
A medication that paired buprenorphine with a second drug was developed as an add-on treatment for depression, and in 2019, the U.S. Food and Drug Administration (FDA) declined to approve it. A good theory is not the same thing as a proven treatment.
While Suboxone does seem to help many patients with their mood, it is not a perfect solution. It may relieve depression only slightly, and for some patients, it may not help at all.
Does this mean that you can stop taking an antidepressant once you start Suboxone? It does not. As the Maudsley Deprescribing Guidelines explain, stopping an antidepressant suddenly can cause withdrawal symptoms of its own, and coming off of one calls for a slow taper with the doctor who prescribes it.
Does Suboxone change your personality?
No, not in the way that people fear. What looks like a personality change is usually the opposite, which is the person’s baseline returning after months or years of active opioid use. The irritability, the secrecy, and the disappearing for hours at a time belonged to the addiction.
It is common for family members to describe these personality changes the same way. The person who seemed to be missing for years is back at the dinner table, calmer and quieter than anyone remembers, and it takes some getting used to. Is that a new personality? Usually, it is the old one.
Of course, not every change is a welcome one. Life without the daily cycle of highs and withdrawal can feel flat at first, and some patients describe feeling tired or emotionally dull in the early weeks. While this often improves with time, it should not be ignored.
What if you really do feel worse on Suboxone?
Genuine side effects do happen. The prescribing information lists insomnia, or trouble sleeping, among the common side effects of Suboxone, and a person who is not sleeping well will not feel like themselves.
Is depression itself on the list? The label does not settle it. In a four month trial of buprenorphine described on the label, about one patient in ten reported depression, but there was no placebo group, and every patient was being treated for opioid dependence.
So, the label cannot tell you that Suboxone never causes low mood. Still, there is little reason to expect it.
If your mood drops after starting Suboxone, do not simply put up with it, and do not solve it by stopping on your own. Tell the doctor who prescribes it. The dose, the timing, your sleep, and your other medications can all be looked at, and there is more on this in the article on why Suboxone might be making you feel worse.
Can stopping Suboxone cause depression?
Yes. This is the one situation where Suboxone really can lead to depression, and it is not uncommon. It happens, in some cases, after you have completed your treatment and stopped taking the medication.
In the days, weeks, and sometimes months after the final dose, you may have withdrawal symptoms, and they may include mild to moderate depression. When symptoms linger this way, it is sometimes called post-acute withdrawal syndrome, or PAWS.
If you feel depressed after stopping Suboxone, it does not mean that you are addicted to Suboxone. These are physical withdrawal symptoms, which means that your body adapted to a medication, the medication is gone, and your brain needs time to adjust.
The prescribing information describes the same thing, stating that buprenorphine produces physical dependence, with withdrawal when it is stopped abruptly or tapered rapidly. It adds that the withdrawal is typically milder than with other opioids and may be delayed in onset.
Is it permanent? In most cases, it is not, although in the middle of it, it can feel as if it will never end. With time, the brain does heal.
Call 911 or go to the nearest emergency room if you or someone close to you:
- is in immediate danger of self-harm
- has used opioids and is breathing slowly, cannot be woken, or has stopped breathing
If you are having thoughts of suicide, call or text 988, the Suicide and Crisis Lifeline, at any hour.
How do you lower the risk of depression after stopping Suboxone?
The first answer is on the label, which says to taper gradually. Stopping suddenly is the hard way down, and there is a separate article on what happens when you quit Suboxone cold turkey.
Yet, how you taper matters as much as whether you taper. The relationship between the dose and the share of receptors that the drug occupies is not a straight line. At a high dose, a reduction leaves most of the receptors still covered, and near the bottom, a cut that looks tiny on paper uncovers a large share of them at once.
Picture a staircase where the steps get taller as you get closer to the ground. While this is not a perfect analogy, it explains why so many patients do well for months and then feel terrible after the last dose. What you want is for someone to build more steps at the bottom, and smaller ones.
In practice, that means reductions sized in proportion to the dose you are on, known as a hyperbolic taper, down to a very low final dose. It is the same principle that the Maudsley Deprescribing Guidelines describe for antidepressants and benzodiazepines. The exact steps are something to work out with your prescriber.
Unfortunately, many patients are pressured to get off of Suboxone quickly, by family members or by programs with a deadline. Fortunately, a taper has no deadline. If a step brings on low mood or other withdrawal symptoms, your doctor must slow the taper down, and you may hold where you are for as long as you need.
Do diet, exercise, and sleep help?
They can help, as support. Regular meals, a steady sleep schedule, and daily movement seem to make the withdrawal period easier, although it has not been shown that any particular diet shortens Suboxone withdrawal.
A moderately paced walk outdoors for 30 to 60 minutes a day is enough for most people, and you may also find that meditation and deep breathing exercises help. None of this replaces a slow taper. It makes a slow taper easier to live with.
If you feel depressed after stopping, should you go back on Suboxone?
At first, you may think that the answer is a clear no. How could it make sense to go back on Suboxone because of Suboxone withdrawal symptoms? You might think that it is like drinking hard liquor in the morning to get rid of a hangover.
In many cases, if you tapered slowly and you felt ready to stop, you will get through the withdrawal period, and the low mood will pass. Yet, fighting through at all costs is not always the right decision. Not everyone does well stopping Suboxone after a set period of time.
If, after stopping Suboxone, you begin to have cravings for opioids, or the old obsessive thoughts return, it may mean that you will do best to resume treatment. Going back on Suboxone does not mean failure. Avoiding a dangerous return to opioids by resuming treatment is a huge success.
Often, when a patient does resume Suboxone, they are able to take a lower dosage than what they were taking before. And, there is no rule that says treatment must end by a certain date. The prescribing information states that there is no maximum recommended duration of maintenance treatment, and that patients may require treatment indefinitely.
There is one more reason to take cravings seriously. After a taper, your tolerance to opioids is much lower than it was, and a dose that you once took routinely can stop your breathing. Talk it through with your doctor, and remember that the decision is yours.
What about naltrexone?
Naltrexone is another option for a person who has stopped Suboxone and is worried about going back to opioids. It is an opioid antagonist, which means that it blocks opioid receptors without turning them on. It is not an opioid, and it does not cause physical dependence.
While naltrexone blocks the kappa receptor as well, and could, in theory, have a similar effect on mood, it should not be counted on. Naltrexone is not a treatment for depression. The label for Vivitrol, the monthly naltrexone injection, asks doctors and families to watch for signs of depression.
Naltrexone also cannot be started right after quitting Suboxone. Given to a person who still has opioids on the receptors, a blocker causes sudden withdrawal symptoms, which is known as precipitated withdrawal. The same label recommends at least 7 to 10 days with no opioids first, and it warns that someone coming off of buprenorphine may be vulnerable to precipitated withdrawal for as long as two weeks.
You may also have read about low dose naltrexone, or LDN. It is a much smaller dose, prepared by a compounding pharmacy and used off label, mostly for certain chronic pain conditions. It is not an established treatment for depression.
Fear of depression should not keep you from starting Suboxone.
If you are avoiding Suboxone because you are worried about depression, now or after you stop someday, you should not be too concerned. There is little reason to expect Suboxone itself to make you depressed, and there is good reason to expect that you will feel better.
Medication-assisted treatment (MAT) is life saving, and it is a much safer way to quit heroin, fentanyl, or pain pills than abstinence-based treatment alone. Depression after stopping, if it comes at all, can be managed with a slow taper and with help from your doctor.
The danger of heroin and fentanyl is today’s danger. When you weigh the risks against the benefits of Suboxone, the benefits often outweigh the risks by a significant margin.
You do not have to decide today how or when your treatment will end. That decision will still be yours when the time comes.
How do I approach Suboxone treatment?
In my practice, buprenorphine films and tablets are prescribed by telemedicine to new patients in Florida, with in-office visits available in Fort Lauderdale. The first dose is taken at home with phone support, and when fentanyl is involved, a low-dose start is used when needed.
Visits are monthly, or weekly when needed, and the patient decides whether the goal is long-term maintenance or an eventual taper.
To ask about starting, continuing, or tapering buprenorphine treatment, please use the contact form.
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.
