Should you take Suboxone, or should you go to rehab?
If you are dependent on opioids, or someone in your family is, you have probably asked this question. You have probably also been given a confident answer by someone who has never prescribed the medication.
While there is no one-size-fits-all answer, I can tell you where I stand. Suboxone treatment in a doctor’s office is not the second-best choice. For many people who are dependent on opioids, it is the better choice, and it deserves to be considered first.
I first wrote this article in 2016, when most rehabs refused to offer Suboxone. A lot has changed since then. Rehabs now advertise the same medication that they once discouraged, and fentanyl has made every return to opioid use more dangerous.
Buprenorphine pushes the button only partway.
Suboxone is a brand name for a film that contains buprenorphine and naloxone. When I say Suboxone here, I use it as a general term for all of the buprenorphine meds that treat opioid dependence, including ZubSolv and the generic films and tablets. I have written about the naloxone in an article on what patients are rarely told about Suboxone.
Opioids work by attaching to opioid receptors in the brain and the body. Imagine that the drug molecule is reaching into the receptor and pushing a button. Heroin, fentanyl, and pain pills push the button all the way in, and the results are pain relief, euphoria, constipation, and slowed breathing.
Buprenorphine pushes the button only partway, which is why it is known as a partial agonist. The Suboxone label describes a ceiling effect. That means that, past a certain dose, taking more does not do much more.
When I first wrote this article, I described buprenorphine as binding to the receptor permanently. That was not accurate. It holds on tightly and lets go slowly, which helps to explain why it is taken once a day.
While the ceiling is one reason that an overdose is less likely than it is with other opioids, it is not a guarantee. The label warns that combining buprenorphine with alcohol, benzodiazepines, or other sedatives can lead to slowed breathing, coma, and death.
If you are prescribed a benzodiazepine, do not stop it suddenly on your own, because stopping abruptly can trigger seizures.
Is Suboxone just trading one drug for another?
Many people who work in addiction treatment believe that recovery requires complete abstinence from all drugs, including the ones that a doctor prescribes. This belief comes from the 12-step programs, Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), which were founded long before Suboxone existed.
For years, most residential rehabs were built on the same foundation. They did not simply decline to offer Suboxone. They discouraged it, and the phrase that patients heard was “trading one drug for another.”
It is not. Suboxone treats opioid addiction. It does not cause it.
It is true that buprenorphine is an opioid, and that a person who takes it every day becomes physically dependent on it. Yet, physical dependence is not addiction.
Addiction means that a person keeps using a drug even though it is causing serious problems in that person’s life. Physical dependence means only that the body has adapted to a medication, and that stopping it suddenly will cause withdrawal.
A patient who takes a steady dose of Suboxone, goes to work, and takes care of a family is not getting high. And, a person who became dependent on a pain medication, taken exactly as a doctor prescribed it, may not be addicted at all. That person does not belong in an addiction program.
What does a month in rehab actually buy?
If you check in to a residential rehab, what will your days consist of? At most programs, the main therapy is group therapy. You sit in a circle with the other residents, and an addiction counselor acts as the moderator.
The other regular activity is the meeting. In the evening, you pile into a van with your fellow residents and ride to a local 12-step meeting, which is free to anyone who walks in.
What about the doctor? Surprisingly, many rehabs do not include regular visits with a physician. Often, a resident sees a doctor or a nurse at admission, and rarely after that.
The staff members that you see every day are addiction counselors. While many of them are dedicated people, a college degree is often not required, and I have heard of people becoming certified in as little as a month.
So, why is rehab so expensive? An analogy that might help is a gym. A gym also employs staff members who have completed a certificate, and they help the members to work out safely. Yet, no gym charges for a month what a rehab charges for a month.
So, before you sign anything, ask how many hours of each week you will spend with a physician.
How effective is rehab?
This is an excellent question, and I cannot give you a number. Few programs publish their results, and each one counts success in its own way.
The traditional plan is a week or two of detox, followed by a month or so of abstinence-based rehab. Often, the length of the stay is set by what the insurance plan will pay for, and not by what your body needs.
While some people have found long-term recovery this way, the model has a particular problem with opioids. It sends people home with their tolerance gone and their cravings intact.
A person who goes back to the old dose after a month away can stop breathing, and with fentanyl, there is often no chance to come back and try again.
So, if you went to rehab and returned to opioids afterward, you did not fail. You were given a plan that took away your tolerance and left out the medication. Even the Suboxone label tells doctors to advise patients of the potential to relapse when the medication is stopped.
In my opinion, parts of the rehab industry profit from the relapse cycle.
What happens when a person relapses after rehab? The advice is to go back to rehab. As usual, it helps to follow the money.
A program that is paid by the stay loses nothing when its graduates return. It is a financial opportunity for a rehab to bill the same insurance card over and over again. As doctors, our first concern should always be the wellbeing and safety of our patients.
To be clear, there are many people working in rehabs who want their patients to get well and never come back. Still, you are allowed to ask any program what becomes of its patients after they leave.
Rehabs now offer Suboxone. Is it as good as seeing a doctor?
If you search for a rehab today, you will find that many of them advertise medication-assisted treatment, or MAT, which means treating opioid dependence with a medication such as buprenorphine. This is a big improvement. Unfortunately, the old attitudes did not disappear when the brochure changed.
One sign is the dose ceiling. Some programs set one low limit for every resident, no matter how much that person was using.
The Suboxone label does not set a maximum dose. It describes a maintenance dose that is adjusted to fit the patient, and it adds that doses above 24 mg of buprenorphine a day, while not studied in randomized trials, may be appropriate for some patients. Your dose is a decision for you and your doctor.
Another sign is the fast taper. Some centers tell patients that the goal is to be off of everything quickly, including the buprenorphine. This would be great if it worked.
In my experience, long-term maintenance works better and saves more lives than a fast taper. The label states that there is no maximum recommended duration of maintenance treatment. When the day comes that you want to taper off of Suboxone, it should be slow, and it should be your decision.
Where will you get your Suboxone after you leave?
This is the one question to ask before you are admitted. A rehab can start the medication, and the staff can watch you take it every morning. The problem is what happens on the day that you are discharged.
It is common for patients to describe leaving a rehab with a few days of medication and no appointment.
So, before you are discharged, ask for the name of the doctor who will continue your prescription, and the date of the first visit. If the rehab started you on a long-acting injection, such as Sublocade or Brixadi, the question is the same. If no one can answer it, find a doctor yourself.
What does “outpatient” actually mean?
The word, outpatient, describes two very different things. The first is a program that works just like inpatient rehab, with the main difference being that you go home to sleep. These programs are usually attached to a residential rehab, and the therapy is the same group circle.
The second kind of outpatient care is a private doctor’s office. You see a physician, you leave with a prescription, and you go home to your family and back to your job. It makes sense that visiting a doctor costs less than living in a facility for a month.
Starting the medication takes some care, because a first dose taken too soon can cause a sudden sickness known as precipitated withdrawal.
While opioid withdrawal is rarely life-threatening, it is so unpleasant that few people can get through it without help. It is easy for someone who has never been through it to say that a person should quit cold turkey and tough it out.
When is inpatient treatment a good idea?
There are people who do better away from home. If you are trying to decide, ask yourself a few questions. What can an inpatient program offer you that you cannot get from a doctor’s office? Have you already tried outpatient treatment, with medication, and found that it was not enough? Is your home a place where you can get well?
If the people you live with are using drugs, or home is not safe, a few weeks somewhere else may be the break that you need. If you drink heavily every day, or take sedatives every day, stopping suddenly can be dangerous, and the withdrawal may need to be medically supervised. And, a mental health emergency belongs in a hospital.
Of course, none of this is about an emergency. If someone has overdosed, or is in danger right now, call 911. If you are in crisis or thinking about suicide, call or text the 988 Suicide and Crisis Lifeline.
Grade every program with a written checklist.
When you call a rehab, the person who answers usually works in admissions. It is not a bad idea to have your questions written down before you dial. In his book, Overcoming Opioid Addiction, Adam Bisaga, M.D., includes a chart for comparing treatment programs, and it can be used as a checklist.
Here are the questions that I would put on the list. Do you offer buprenorphine, and can it be started on the first day? Is there a limit on the dose? Will I be tapered off before I leave, or may I stay on it?
How often will I see a physician, as opposed to a counselor? Are 12-step meetings required? Who will prescribe my medication after discharge, and when is the first appointment? What will the total cost be, in writing?
Write down the answers, and compare the programs side by side. While the decision is yours, it is best to include a trusted family member, because a person in withdrawal is in no position to negotiate.
If a program will not answer a plain question, that is an answer.
Who can prescribe Suboxone now, and where should you not go?
In 2016, a doctor needed a special federal waiver to prescribe Suboxone, and could treat only a limited number of patients.
Congress eliminated the waiver in the Consolidated Appropriations Act, 2023, which was signed on December 29, 2022. Today, a doctor whose Drug Enforcement Administration (DEA) registration covers Schedule III medications may prescribe it, and there is no federal limit on the number of patients.
That means that your own family doctor is allowed to treat you. Unfortunately, being allowed is not the same as being willing, and I have written separately about who can prescribe Suboxone and how to choose a doctor. A Suboxone doctor by telemedicine is also a legitimate option.
While some pain clinic doctors prescribe Suboxone well, I recommend against going to a pain clinic for help to quit opioids.
They say that if you hang around a barbershop long enough, you are going to get a haircut. A waiting room full of people who are waiting for the same pills that you are trying to leave behind is not the best place to sit.
Do you have to see a therapist, or go to meetings?
The answer is no. The Suboxone label describes the medication as part of a complete treatment plan that includes counseling and psychosocial support. It does not say that you must sit in a group circle, and I believe that neither therapy nor meetings should be a condition of getting the medication.
If you want to work with a therapist, your doctor can refer you to one.
Years ago, I wrote NA meetings into my patients’ notes as an order, as if a meeting were a prescription. I no longer do that. Most meetings are not moderated by a professional, members are encouraged to share private health information with strangers, and NA’s position discourages the medical treatment that I provide.
Still, if meetings improve your life, you should go. If one meeting makes it harder for you to stay well, find another meeting, or another kind of support group.
What the members of a meeting should not do is practice medicine, by telling a newcomer to stop a medication that may be keeping that person alive. Your medical treatment is between you and your doctor.
The decision belongs to you.
Please decide with the facts in front of you. Treatment with Suboxone in a doctor’s office is not a consolation prize for people who could not manage rehab. It is medical treatment, and for opioid dependence, I believe that it is where most people should start.
Weigh your options, bring someone you trust, and ask your questions out loud.
How do I treat opioid dependence?
I provide buprenorphine treatment, with Suboxone and its film and tablet generics, to new patients in Florida by telemedicine, with in-office visits available in Fort Lauderdale. Patients start at home with phone support, and when fentanyl is involved, I use a low-dose start when needed.
My practice is concierge and not insurance-based, and visits are monthly, or weekly when needed. There are no mandatory group meetings, and the patient decides whether the goal is long-term maintenance or a gradual taper.
To ask about buprenorphine treatment, please reach my office through 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.
