Suboxone VS Subutex

Suboxone VS Subutex

Why do doctors prefer prescribing Suboxone over Subutex?  Some patients complain that the additional ingredient in Suboxone, which is called Naloxone, causes side effects.  They ask their doctors if they can be switched to Subutex, which does not contain Naloxone.  Often, the doctor will say no.

Naloxone is not absorbed orally or under the tongue.  It is inactive when Suboxone is taken as directed.  The only purpose it serves as an ingredient of Suboxone is as an abuse deterrent.  It is expected that sophisticated drug abusers are aware of its existence and what will happen if they attempt to manipulate Suboxone to be injected with a syringe and needle into a vein.  When Suboxone is abused in this way, it will make the IV drug abuser very sick.  To this type of addict, Naloxone serves the purpose of being a psychological deterrent.

The addict who has a history of IV drug abuse may secretly appreciate the presence of Naloxone.  While they may outwardly complain about being prescribed Suboxone, they may be internally be grateful.  Addiction is a disease that forces the addict to lie in order to get high.  An addict may be screaming for help inside, but is unable to ask for help because their addiction is controlling them in the direction of being able to get high again.

While this may be true of the addict who has experience with IV drug use and preparing and injecting opioid tablets, the majority of opioid dependent people do not use or abuse opioids in this way.  As the CDC states in the recent report on opioid prescribing, the most common form of abuse is taking opioids orally.  For these people, using Naloxone as an abuse deterrent is useless.  Naloxone does nothing to prevent abuse by taking intact tablets by mouth, the way they were meant to be taken, though often in excess.  So, naloxone provides no benefit at all to most patients who are prescribed Suboxone.

Does naloxone cause side effects when taken orally?  It is not likely, but it is possible.  Naloxone is poorly absorbed when taken orally, but it does show up on drug tests, so it clearly is present in the blood stream, though in small amounts.

One reason for a doctor to prescribe Subutex, the one without Naloxone, is for pregnant women.  Buprenorphine combined with Naloxone is not to be taken by pregnant women.  Should Buprenorphine and Naloxone be given at all to women of child bearing age? That is a good question.  Is it worth taking a chance? Does the risk of an IV drug abuser adulterating a Suboxone film and injecting it outweigh the risk to a fetus?  What if the doctor finds out about the pregnancy when it is too late to change therapy?

That is a question that needs to be answered in general by the experts.  Does the benefit outweigh the risks? Are we saving lives by including naloxone?

The real issue may be how physicians are kept in line by a system of laws and rules.  A physician can be disciplined for practicing outside of the standard of care. If most doctors are prescribing Suboxone and experts agree that Suboxone is the better choice, an argument can be made that a doctor who mostly prescribes Subutex is doing something wrong.

There is also the issue of regulatory oversight.  Doctors who are registered to prescribe buprenorphine for opioid dependence are subject to audits by the government.  The practice liaisons for the company that makes Suboxone have made it very clear to doctors that some government regulators do not like to see prescriptions for Subutex. Of course, this would appear to be a conflict of interest on the part of the manufacturer.

Doctors prescribe suboxone over subutex for two reasons.  First, they assume that all patients are potential IV drug abusers as a universal precaution.  There is always the possibility of any patient not being completely truthful about their drug using history.  This is not at all a moral deficiency.  It is simply the consequence of the physical effects of addiction on the brain.

Second, doctors are afraid of discipline.  They are regulated by many agencies at many levels.  Federal, state and local law enforcement and administrative enforcement.  Investigators in many forms may visit doctors openly or covertly.  They are often motivated to find any deficiencies in the doctor’s practice.  Doctors practice defensively for this reason. It does not make them malicious, it is simply a consequence of the nature of the system.

Instead of patients blaming the doctors and doctors blaming the patients, we should all demand that experts in the field come forth and make it clear that choosing Suboxone over Subutex has a scientific basis and not a profit motive by large pharmaceutical corporations.  What would happen if naloxone were removed from the equation? Would there be a significant increase in adverse events?  If not, why are doctors pressured to prescribe medications containing naloxone as an abuse deterrent?  Lives are already at risk due to opioid addiction and the most important thing is to save as many lives as possible.

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