Is sleeplessness one of the side effects of Suboxone?
Most people are worried about Suboxone making them tired when they first start taking it. It is, after all, classified as an opioid. Yet, once they start, they find that they can function well all day without the sleepiness and nodding off that other opioids cause.
Unfortunately, a small percentage of patients taking Suboxone, or a similar buprenorphine medication, discover that they have trouble sleeping. Mark Leeds, D.O., an osteopathic physician with over two decades of experience in treating medication and drug dependence and addiction, hears the complaint often. A common pattern is the patient who expected to be groggy and instead lies awake at two in the morning with a clear head, wondering whether the medication is working at all. It is working. A clear head is what the medication is supposed to give you.
The product information for Suboxone lists insomnia among the common side effects. Yet, the same product information shows that patients taking a placebo reported insomnia about as often as patients taking Suboxone. So, the label does not settle the question. Clinical experience has to.
Suboxone here means any of the buprenorphine medications that treat opioid dependence, ZubSolv and the generic films included. The buprenorphine does the work, and the small amount of naloxone in the film is there to discourage injecting it. So, is it the Suboxone keeping you awake? Is it the fentanyl you stopped last week? Or, is it something the opioids had been hiding all along?
Early in treatment, the insomnia is often the old opioid leaving, not the new one arriving.
Street opioids are powerful sedatives. A brain put to sleep by fentanyl every night for years has forgotten how to fall asleep on its own. Suboxone makes quitting much easier, yet, the detox is still happening in the background during early recovery.
This background withdrawal is a common cause of early sleep trouble, and it is not the buprenorphine’s fault. Fortunately, it fades over the first weeks and months, as the brain relearns how to sleep without a sedative. And, when the night is no longer filled with the search for the next dose, guilt, grief, and regret come up in the quiet, and sleep does not come easily with those in the room.
Still, it does appear that Suboxone itself causes insomnia for some patients. This is because a change to the Suboxone routine often fixes the sleep.
Does Suboxone cause nightmares?
Some patients report vivid dreams, or outright nightmares, after starting Suboxone. Opioids as a class tend to cut into deep sleep and into dream sleep, the stage known as REM, or rapid eye movement, sleep. Whether buprenorphine does this to the same degree in people has not been well studied, so no one knows for certain.
One theory is that the dreams come from the drug that was stopped, not the one that was started. When a drug that suppresses dream sleep is taken away, dreaming tends to come back stronger for a while, as if the brain were catching up, and nightmares are part of dreaming.
Are the dreams dangerous? No. They are unpleasant, and in most patients they fade within the first weeks. If nightmares are making you dread going to bed, tell your doctor. The timing changes that help with insomnia often help with the dreams as well.
Does the timing of when you take Suboxone affect insomnia?
Taking Suboxone too close to bedtime may keep you awake. While this seems like an obvious fix, there has to be a balance of not taking it too early or too late.
How often should you take it? The product information says to take Suboxone as a single daily dose, and many doctors prefer it that way, on the theory that a patient should think about taking medication as little as possible.
Unfortunately, in the real world, once daily dosing rarely works out to be ideal. Buprenorphine has a long half-life, somewhere between one and two days for most people, but the level peaks for a much shorter time. Patients often complain that the whole day’s dose at once feels too strong in the morning and wears off too much by evening.
While this is not a perfect analogy, taking a day’s Suboxone all at once is like eating the whole day’s food at breakfast. You are stuffed at nine in the morning and hungry again by dinner. So, many doctors recommend that patients divide the dose and take half in the morning and half in the evening.
Twice daily dosing usually works out very well.
In Dr. Leeds’ observation, twice daily dosing has not made anyone’s addictive thinking worse. Patients do not mind taking Suboxone twice a day if it means never feeling over-medicated or under-medicated. Nobody has ever become obsessed with a blood pressure pill by taking it twice a day.
A person who is addicted to opioids cannot think of anything other than the next dose, and when it arrives, the mind is already on the one after that. That obsession goes away with Suboxone treatment, whether it is taken once a day or twice.
The doses should be about eight to twelve hours apart. There is also a monthly buprenorphine injection for patients who would rather not think about daily doses at all, and it has trade-offs of its own to discuss with your doctor. If you take films or tablets, splitting the dose is the simplest fix.
Can you take Suboxone at night?
Yes, many patients take a dose in the evening, and for some it is the more important dose of the day. Patients new to treatment often want the evening dose to land close to the hour when they would otherwise have been out looking for fentanyl, because that is when the cravings come.
Yet, taking the evening dose too late may lead to insomnia. As you can imagine, moving the evening dose up by an hour or two may be all it takes.
Another option is to take a larger amount earlier and a smaller amount in the evening. Ask your doctor whether it makes sense to take two-thirds of the dose in the morning and one-third later. There are other ways to divide the daily dose. The right split is worked out with your doctor, not on your own.
What about just taking less Suboxone to help with insomnia?
Suboxone side effects may be related to taking more than you need. Doctors often start a new patient on a higher dose on purpose, because a dose that is too low leaves cravings that can lead to relapse. Once the cravings are under control, the dose may be more than the patient needs.
While Suboxone has a ceiling effect that keeps the risk of dangerous over-medication low, side effects can show up well inside the approved dose range. The product information gives a maintenance range of 4 mg to 24 mg of buprenorphine per day, and as an illustration only, a person who cannot fall asleep at 16 mg may sleep better at 12 mg or 14 mg.
If reducing the dose is the answer, the change may not need to be large. Any change must be worked out with your doctor, because reducing too early or too far brings back cravings, and that risk is highest early in treatment. When you are ready, your doctor will help you to reduce it gradually.
Suboxone is not a sleeping pill, and quitting it over insomnia is a bad trade.
There are two mistakes that patients make here. The first is taking an extra dose at bedtime, on the theory that Suboxone is an opioid and opioids make people sleepy. For a patient who has been on opioids, buprenorphine is not sedating enough to work as a sleeping pill. It is not approved for that, and an extra dose at bedtime only makes the timing problem worse.
The second mistake is stopping Suboxone altogether because of a few bad nights. Quitting buprenorphine cold turkey brings on opioid withdrawal, which is a far worse insomnia than the one you have now. Worse, it opens the door to relapse, and a relapse on today’s fentanyl supply is deadly.
Physical dependence on buprenorphine is expected in maintenance treatment. It is not addiction, and it is not a failure of the treatment. Insomnia is a side effect to be adjusted around, not a reason to throw away the medication that is keeping you alive.
How long does Suboxone insomnia last?
In practice, Suboxone insomnia usually settles over the first weeks, once the dose and the timing are adjusted. The part that comes from the old opioid leaving takes longer, and the brain needs the first few months to relearn normal sleep. Everyone is different, and no one can promise a date.
If the insomnia is still there after the dosing has been worked out and the early months have passed, something else is going on, and your doctor will want to look for it. So, what can you take in the meantime?
What can you take to sleep while on Suboxone?
A person leaving one physical dependence should not be handed another one. So, sleep medication belongs at the end of the list, as a short-term last resort. What comes before it?
Sleep hygiene comes first. With your new alertness, you may find that you have rediscovered books, shows, and interests you neglected for years, and that all of it now happens at midnight. Put the phone out of the bedroom, use the bed only for sleep, get up at the same time every day, and stop the caffeine by early afternoon.
Sound comes second. Relaxing recordings help some people drift off and get back to sleep after waking. Binaural beats play a slightly different tone in each ear, and isochronic tones pulse in the sound itself, so they work without headphones.
While there is not much formal evidence for sound programs, they are harmless. It is much safer to listen to sounds that make you sleepy than to take another pill.
Over-the-counter options come third, with your doctor’s knowledge. While part of what melatonin does may be placebo, it has a low risk of side effects or drug interactions, and a harmless placebo for sleep is not a bad thing.
Sleep aids such as Unisom contain a sedating antihistamine, diphenhydramine or doxylamine, which some people swear by and which leaves others groggy without much real sleep. Check with your doctor before starting any of these, even the ones sold next to the vitamins.
What about prescription sleeping pills with Suboxone?
Suboxone doctors are wary of prescribing sleeping medications, and they are right to be. The sleeping pills approved for insomnia are benzodiazepines, such as Restoril (temazepam), and the z-drugs, such as Ambien (zolpidem) and Lunesta (eszopiclone). The Suboxone product information itself says that benzodiazepines are not the treatment of choice for anxiety or insomnia in a person taking buprenorphine.
There are two reasons. The ceiling effect that protects a Suboxone patient from overdose goes away when sedating drugs are added, and buprenorphine combined with benzodiazepines, z-drugs, or alcohol can cause breathing to stop. If a person on Suboxone cannot be woken or is breathing slowly, call 911.
And, these drugs cause a physical dependence of their own that can be far harder to get out of than the one you just treated. Dr. Leeds spends most of his days helping patients taper off of exactly these medications.
If you already take a benzodiazepine or a z-drug, do not stop it on your own because of this article. Stopping a benzodiazepine suddenly can cause seizures, and coming off of either one is its own gradual taper, planned with your prescriber.
Some doctors use trazodone, an older antidepressant, off-label for sleep. It is not a controlled substance, but it has drug interactions and a withdrawal syndrome of its own. In this practice, patients more often ask for help coming off of it than for help starting it.
What should not be done for Suboxone insomnia?
There is a drug that many people around the world use on a regular basis to help them get to sleep. It is widely available and easy to purchase at almost any store that sells food and drink. Unfortunately, it is also one of the most deadly and harmful drugs in the world. As you may have guessed, this drug is alcohol.
Whatever you do, do not use alcohol as a sleep aid, especially if you take Suboxone. While other drugs can increase the risk of overdose when combined with Suboxone, alcohol is particularly dangerous, even one drink to help you fall asleep.
If you already drink, let your doctor know, so that the drinking can be treated alongside the opioid dependence. You may even find that Suboxone makes it easier to stop. Alcohol is not the solution to Suboxone insomnia. It is not worth the risk.
What else should you do if you cannot sleep because of Suboxone?
Your doctor may want to look for a cause that has nothing to do with the medication. Many health conditions are masked by opioid use and then revealed when the addiction is treated. Could you have had sleep apnea for years and never known it? It is possible, because the opioids covered it up.
Opioids, including buprenorphine, can also cause a breathing pattern in sleep called central sleep apnea, and your doctor may adjust the dose if that turns out to be the problem. A formal sleep study settles the apnea question. When a CPAP machine, a continuous positive airway pressure device worn at night, is needed, it changes a person’s nights completely.
Otherwise, your doctor will look at the other usual suspects. An overactive thyroid keeps people awake. So does anxiety or depression, which often drives insomnia in early treatment and deserves its own attention rather than another pill at bedtime.
Just because you have a side effect from treatment does not mean you must live with it. Sweating, constipation, headaches, ankle swelling, and insomnia can all be addressed, and a side effect may be pointing to something that needed attention anyway. Your doctor wants to hear from you, so do not worry about being a nuisance.
Dr. Leeds treats opioid dependence with buprenorphine by telemedicine throughout Florida, and dose timing is worked out with each patient as a partner. Weekly video visits and text access in between mean that a split dose, an earlier evening dose, or a small reduction can be tried and adjusted within days rather than endured until the next monthly appointment.
If Suboxone is keeping you awake, contact Dr. Leeds through the contact form to talk about your dosing schedule.
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.
