Suboxone or Rehab?

Suboxone VS Rehab

What are Suboxone and Subutex?  Should I take Suboxone or go to Rehab?  

There is no easy, one-size-fits-all answer to these questions.  We will explore these topics in this article and shine some light on the subject.

These two prescription medications, Suboxone and Subutex, are used to treat opioid dependence.

Opioids are a class of drugs that include heroin and many prescription pain medications.  Psychological dependence on opioids is a form of drug addiction.  This means that a person continues with use or misuse of the drug even though it is causing problems in their life.  The brain is reprogrammed to believe that drug use is necessary for survival, causing reoccurring thoughts of the need to use again.  These thoughts are called cravings.

What is Subutex?

Subutex is a brand name for the medication, buprenorphine.  It is a brand that is no longer on the market.  The generic buprenorphine is still available.  The name is still used when discussing buprenorphine to be used to treat opioid dependence.

What is Buprenophine?

Buprenorphine is a medication that is unique in the way it works in the human body.  It is not absorbed in the gastrointestinal tract, so swallowing this medication will have no effect.  The proper way to take it is to place the tablet or film under the tongue and allow it up to ten minutes to fully absorb.  Once in the blood stream, buprenorphine targets opioid receptors.  These receptors, when activated by most opioids, will have specific effects, including pain relief, euphoria, constipation, slowed breathing and other effects.

Pain relief is the desired effect when prescription opioids are prescribed by a doctor for the management of pain.  Euphoria (feeling good), while considered to be a side effect, is the main desired effect of the recreational drug abuser and addict.  When an opioid attaches to a receptor, it briefly binds itself to the receptor and then activates it to cause these effects.  Imagine that the drug molecule is reaching into the receptor and pushing a button to activate it.

Buprenophine is a type of opioid, but it works differently than most opioids.

It binds to opioid receptors, but it does not do it briefly, it binds permanently.  That’s right.  The buprenorphine molecule will bind and block a receptor so it can never be used again by other opioids.  So how do the effects ever wear off if the receptor is permanently blocked?  Receptors don’t last forever.  They degrade and go away within three days.  New ones are forming all the time.  When buprenorphine binds and blocks a receptor, it does something unique that other opioid receptor blocking drugs do not do.  Buprenorphine also partially activates the receptor.  Imagine that the molecule is reaching into the receptor and pushing a button to activate it but not pushing it all the way in.  The result is that buprenorphine makes it possible for opioid dependent patients to quit taking opioid drugs with very little down time.

In the beginning, there is a necessary short time period in which the patient must quit their drugs and feel just a little sick before taking the first dose of buprenorphine.

This is due to the unique mechanism of action in the body of buprenorphine.  If taken properly, this incredible medication will prevent ongoing withdrawal symptoms and prevent cravings in the opioid addict.  It will also provide pain relief for patients who have chronic pain issues.  In addition to these benefits, buprenophine generally does not cause the sedation and clouded thinking that characterizes opioid abuse.  It also has what is called a ceiling effect meaning that the risk of overdose with buprenorphine is far less than the risk of overdose with other opioids unless it is combined with other drugs of abuse.

What is Suboxone?

Suboxone is another brand name for buprenorphine, but in this case, there is an additional ingredient.  The second ingredient is Naloxone.  Naloxone is a medication that is used in emergency situations to reverse the effects of opioid overdose.  When a person takes too much of an opioid, it causes their breathing to slow down and even stop.  Giving naloxone by injection reverses all effects of the opioid and can save lives.  It is not a pleasant experience to get a naloxone injection because it also causes precipitated withdrawal, however it is a life saving treatment.

There is a different reason for including Naloxone in Suboxone.

It is to psychologically protect the recovering opioid addict from temptation to use Suboxone as an injectable drug.  If Suboxone is prepared by the addict to inject and it is injected into a vein, the Naloxone component will cause precipitated withdrawal and will be a very unpleasant experience.  Knowing this, the recovering addict with a prescription for Suboxone will not be tempted to try this and will be psychologically protected in this regard.

What is withdrawal?

Opioid withdrawal is an unpleasant physical syndrome that occurs when a person who is dependent on opioids stops taking their drugs.  As the opioids leave the system, the person will experience a variety of unpleasant symptoms.  These combined symptoms are so unpleasant and long lasting that they can cause an addict to avoid discontinuing drug use for many years.  These symptoms are similar to flu symptoms but far more severe.  They include muscle aches, cold sweats, gastrointestinal upset including diarrhea.  It is easy for a non-addict to say that an addict should just tough it out and get through the withdrawal, but that is easier said than done.  It cannot be emphasized enough how unpleasant this experience can be and taking more opioids immediately relieves these symptoms.

Why would an opioid dependent person want to see a doctor and get a prescription for Suboxone?

The main reason is that the person wants to stop using drugs.  They have become aware of the problems in their life and suspect that the drug use is the root of these problems.  When a person is ready to stop taking drugs and finds that they cannot do this on their own, they look for help.  There is a lot of information and misinformation online and elsewhere.  A person may start at their church or synagogue.  They may visit their family doctor or visit a psychiatrist.  Sometimes there is an awakening to the problem when a person is arrested and court ordered to get help.  Along the path to seeking answers, a person may come across information about Suboxone and how successful treatment can be for opioid dependence when Suboxone is part of the treatment regimen.

Why would a person who is opioid dependent not want to see a doctor to get a prescription for Suboxone?

Many people involved in the field of drug addiction treatment believe in complete abstinence from all drugs in order to recover.  This is based on the philosophy of Narcotics Anonymous, a 12 step program of recovery.  NA was formed in the 1950s.  While it is an excellent program, it is a one-size-fits-all program.  Much of the literature and philosophy of the program predates recent developments in modern medicine.  Suboxone taken long term as part of a maintenance program is life saving for many individuals.  There is a difference in the recovery process involved with various drugs.  Opioids, when abused by an addict, are particularly dangerous.  When an addict relapses and uses an opioid, it is like Russian Roulette.  There is a very high chance of overdose death.  Often, there is no chance of coming back to pick up the NA white chip.

Opioids are the most dangerous of drugs.

With other drugs, such as methamphetamine, cocaine, crack, marijuana, while potentially dangerous, these drugs when used in a relapse, are more often survivable relative to opioids.  That is not to say that other drugs do not kill.  They just don’t kill as easily and as frequently.  Another frightening issue is profit motivation.  There have been stories written about addiction treatment programs and rehabs that benefit when an addict relapses and returns for ongoing drug treatment.  It is a financial opportunity for an addiction rehab to bill a patient’s insurance card over and over again.

As health care providers, our motivation and primary concern should always be the wellbeing and safety of our patients.  The United States Surgeon General has recently urged American health care providers to educate patients about the medical, scientifically proven ways that we can save lives from opioid addiction.  “Complete abstinence from all drugs” is not the answer when that is meant to include withholding proven medical treatment such as Suboxone.

Should recovering opioid addicts avoid Narcotics Anonymous meetings?

This is not an easy question to answer.  Narcotics Anonymous (NA) is an excellent program, but its members should not be administering medical treatment by telling newcomers that they should avoid proven life saving therapy.  Some patients who take Suboxone have chosen to go to Alcoholics Anonymous (AA) because there is, in some cases, more tolerance for the prescribed use of Suboxone.  NA is still a very good program and it is possible to find a sponsor who is enlightened and understands that a patient who is prescribed Suboxone and takes it as directed and no other drugs should be considered to be clean.

Do I have to see a therapist?  Do I have to go to meetings?

It is considered to be part of the program of treatment for opioid dependence to get some form of psychotherapy along with a prescription for Suboxone.  This requirement can be satisfied by visits to a psychologist or other licensed mental healthcare professional who has experience in working with recovering opioid addicts.  Going to 12-step meetings in addition to medication and therapy is a personal decision.  If meetings help to prevent relapse and improve your life, you should go.  However, you should not go if it makes it more difficult for you to stay clean. You should discuss this with your therapist.  If meetings are making things more difficult, often the solution is to find other meetings and other recovering addicts.  As they say, principles should come before personalities.  There are other types of support meetings besides 12-step meetings.

How do I get more information about getting a prescription for Suboxone?

This is a good question.  Not all doctors are able to prescribe Suboxone for the treatment of opioid dependence.  There are special training requirements that must be satisfied.  In the first year after obtaining this waiver, a doctor may treat up to thirty patients.  At the end of the first year, the doctor may apply for an increase to 100 patients.  Some doctors who are registered decide to stop treating addiction.  They may still be registered and show up in searches for doctors.  These doctors do not want to worry about periodic DEA practice audits. They would rather avoid disruptions of their practice.  Another concerning trend is the combination of pain management with Suboxone prescribing.

If you are looking for help to quit taking opioids, avoid pain clinics and marijuana clinics.

Pain clinics see the prescribing of Suboxone for opioid dependence to be an additional financial opportunity.  They say that if you hang around a barbershop long enough, you are going to get a haircut.  Sitting in a waiting room of a pain clinic is not the best place for a recovering addict.  Another problematic practice is treatment centers that believe in fast tapering from Suboxone or Subutex.  These centers tell patients that the goal is to achieve complete abstinence quickly.  This is would be great if it worked. But, experience and studies have proven that longer term maintenance works better and saves more lives than fast tapering.  These issues should all be considered in seeking help from a doctor when there is a problem with opioid addiction.

As you can see, answering the question, “Should I take Suboxone or go to Rehab?”, involves a personal decision and much thought.  I hope that this article has provided some insight.  Further discussion is encouraged in the comments.

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