What is the difference between Suboxone and Subutex?
There is one difference between Suboxone and Subutex, and it is naloxone. Suboxone contains buprenorphine and naloxone, and Subutex contains buprenorphine alone. Both dissolve under the tongue, and both treat opioid dependence with the same active drug at the same doses.
This page is by Dr. Leeds, an osteopathic physician and deprescribing specialist. In over two decades of treating opioid dependence, the Suboxone vs Subutex question has come up at nearly every first visit, and it usually comes up the same way. The patient asks for Subutex, and the doctor says no.
So, if the medicine that does the work is the same in both, why are there two products at all? Why does nearly every prescription say Suboxone? And, is the Subutex in the question even the same thing it was fifteen years ago?
Why has Subutex been discontinued?
The brand named Subutex has not been sold in the United States since 2011. The company that made it stopped selling the brand-name tablets, and a year or two later it stopped selling brand-name Suboxone tablets as well, leaving the film.
Was either one a safety recall? No. They were business decisions, and the generic tablets never went away. While the brands are gone, the two brand names have outlived them.
So, when a patient asks for Subutex today, they are asking for generic buprenorphine, a plain sublingual tablet with no naloxone in it. When they say Suboxone, they usually mean the film, though generic buprenorphine and naloxone tablets and films, and Zubsolv, are the same combination under other names.
I will use the names the way patients use them. In this article, Subutex means buprenorphine alone, and Suboxone means buprenorphine with naloxone. What matters is what is in the tablet, not what is printed on the box.
What does naloxone do in Suboxone?
Naloxone is an opioid blocker. On its own, as Narcan, it is sprayed into the nose or injected to reverse an opioid overdose, and it has saved more lives than any drug I can think of. In Suboxone it does something much less dramatic. It sits there.
Naloxone is poorly absorbed under the tongue. When you take Suboxone the way it was meant to be taken, the buprenorphine is absorbed and goes to work, and the naloxone mostly goes nowhere. In fact, a trace of it shows up in the blood and on a drug test, and that is about all it does.
The naloxone was put there for one situation. If someone dissolves a Suboxone film and injects it, the naloxone is fully absorbed, it blocks the opioid receptors all at once, and the person gets very sick, very fast. Naloxone is a deterrent to injecting the medication, and nothing more.
An analogy that might help is a car alarm. If you get into your car with the key, the alarm never makes a sound, and you may forget it is there. It only goes off if someone breaks a window.
While this is not a perfect analogy, it fixes the main idea in place. Naloxone is the alarm, buprenorphine is the engine, and the engine is the same in both products.
Does the naloxone actually stop anyone?
This is where I part ways with the way the subject is usually taught. The alarm only matters to a person who was going to break the window, and that is a minority of the people who take buprenorphine. In my experience, most people who misuse an opioid medication misuse it the plain way, by mouth, by taking more than they were told, and naloxone does nothing about that.
For a person with a history of using a needle, the naloxone is real. It is a psychological deterrent, and I have come to believe that some of those patients, whatever they say out loud about being made to take Suboxone, are quietly grateful for it. Addiction pushes a person toward the next dose and away from asking for help, and a built-in reason not to inject can be a relief.
Yet, for everyone else, the naloxone is dead weight. It does not make the medication safer, it does not make it work better, and it does not stop anyone from swallowing a second tablet. So, naloxone is not much of a deterrent after all.
Does it cause side effects when it is barely absorbed? Not likely, but possible, and patients have told me that the combination sat badly with them and the plain tablet did not.
A documented reaction to naloxone is a legitimate medical reason to prescribe buprenorphine alone, and a patient who reports one deserves to be taken seriously rather than suspected. If your medication is making you feel worse, that has more than one possible cause. It is worth a conversation with your doctor.
Does Subutex have a blocker?
Yes, it does, and the blocker in Subutex is buprenorphine. Patients are surprised by this because they have been told that naloxone is “the blocker” in Suboxone, and that Subutex has none. While naloxone is a blocker, it is not the only one in the tablet.
A drug that stimulates a receptor is known as an agonist, and a drug that blocks a receptor is an antagonist. Buprenorphine is both. It is a partial opioid agonist, which means it settles onto the opioid receptor and turns it on part of the way.
It also holds onto that receptor more tightly than heroin, oxycodone, or fentanyl, and it holds on for a long time. A receptor that buprenorphine is sitting on is a receptor that another opioid cannot use.
That is the mechanism behind everything buprenorphine does well. It quiets withdrawal and craving because the receptors are occupied and partly active, it has a ceiling beyond which more medication does not do more, and it blocks other opioids because there is nowhere for them to land. The blocking is not a separate ingredient. It is the buprenorphine.
Of course, a drug that holds onto the receptor every day produces physical dependence, and the prescribing information says so plainly. Physical dependence is not addiction. Dependence is what the body does with any opioid it receives daily, and it is why buprenorphine is tapered off of slowly if that day comes. Addiction is the loss of control, and that is the part the occupied receptor quiets.
So, the answer to “does Subutex have a blocker” is that the blocker is the medicine itself. Naloxone adds a second one for the needle. Under the tongue, the naloxone does not count.
Is Subutex better than Suboxone for starting treatment sooner?
No. There is a belief on the street, and it has reached my office more than once, that Subutex lets you start sooner after your last dose because it “doesn’t have a blocker.” That belief is wrong twice over.
Precipitated withdrawal, the sudden and severe withdrawal that hits when buprenorphine is started too soon, is caused by buprenorphine. It arrives on the receptor, pushes the heroin or fentanyl or oxycodone off, and replaces a full signal with a partial one, all at once. Naloxone has very little to do with it, because so little naloxone is absorbed under the tongue, though the label does note that the small amount absorbed can make precipitated withdrawal worse for someone coming off methadone or another long-acting opioid. I have a separate page on what precipitated withdrawal is and why it happens.
That means the wait is the same for both products. You must be in withdrawal before the first dose, not merely past the last one, and doctors score that withdrawal with a checklist, the Clinical Opiate Withdrawal Scale, or COWS, rather than guessing from the clock. With a short-acting opioid the wait is usually measured in hours to about a day. I have written about how long you have to wait after using.
Fentanyl is different. It builds up in body fat and, in my experience, can keep leaking back out for days, so the wait is often longer and much harder to judge, and that is why low-dose induction exists. How long to wait is a decision for you and your doctor, not a number to copy from a website, including this one.
And, is Subutex more euphoric than Suboxone? Also no. Taken under the tongue, both deliver the same buprenorphine at the same dose with the same ceiling, and a person who is already tolerant to opioids does not get high from either one. Buprenorphine works very well for treating opioid dependence and very poorly as a drug for getting high, and that is true whichever box it came in.
Why do doctors prescribe Suboxone instead of Subutex?
Doctors default to the combination for three reasons, and only one of them is about the patient in front of them. The first is a universal precaution. While a doctor cannot know who will inject and who will not, asking does not settle it, because a person in active addiction is not always able to be truthful about it.
That is not a moral failing. It is what the condition does to a person, and prescribing as though anyone might inject is a way of protecting everyone.
The second reason is fear. For more than twenty years, a doctor needed a federal waiver to prescribe buprenorphine for opioid dependence, and waivered doctors were subject to audits and inspections at several levels of government. Congress removed that waiver in the Mainstreaming Addiction Treatment Act at the end of 2022, and the paperwork went with it.
Yet, the habit of defensive prescribing did not go with it. In my experience, pharmacies, insurers, and medical boards still treat a Subutex prescription as something that needs explaining. Doctors practice defensively for this reason, and it does not make them malicious. It is a consequence of the system they work in.
The third reason is marketing, and I saw it firsthand. Years ago, the practice liaisons for the company that made Suboxone made it clear to prescribers like me that regulators did not like to see prescriptions for Subutex. Perhaps that was true. Coming from the company that sold the product with naloxone in it, it was also a conflict of interest, and I said so at the time.
Where is the science in all this? I have asked for years what would happen if naloxone were removed from the equation, and whether anyone has shown a rise in harm when patients take buprenorphine alone under the tongue. I have not seen it. In my opinion, the near-universal preference for the combination rests on caution, regulation, and manufacturer messaging far more than on evidence. A decision this common deserves better than that.
When is Subutex the right choice?
There are three situations where I reach for buprenorphine alone, and pregnancy is the one people know about. Years ago, on this same page, I wrote that the combination was not considered safe in pregnancy. That was the teaching at the time, and I owe readers a correction, because it rested on a shortage of data about naloxone, not on evidence that naloxone had harmed anyone.
Does that make the combination unsafe in pregnancy? It does not. The prescribing information for Suboxone does not list pregnancy as a contraindication, and it describes the data on buprenorphine in pregnancy as limited but not pointing to an increased risk of birth defects from buprenorphine.
What the label does warn is that a baby exposed for a long time before birth should be expected to have withdrawal after birth, which is treatable. Still, many doctors prefer the plain tablet in pregnancy because it has the longer track record, and that is a preference, not a rule. A pregnant patient who is stable on the combination is not taking something dangerous.
The second situation is a documented allergic reaction to naloxone, which the prescribing information lists as a contraindication. Fortunately, a patient who has had one belongs on buprenorphine alone, and there is nothing to argue about. The third is observed dosing, because hospitals and treatment programs that watch each dose go under the tongue often use the plain tablets, and the naloxone has no job to do when a nurse is standing there.
Outside of those, and the label’s own preference for the plain tablet when starting someone who is coming off methadone or who has serious liver disease, the two products are interchangeable when they are used as directed. If you tolerate the combination, there is no medical reason to switch. If you do not, there is no medical reason to refuse.
Are patients and doctors on opposite sides of this?
Unfortunately, the way this question usually plays out leaves both people feeling accused. The patient asks for Subutex because of a side effect, a taste, or a price, and hears a no that sounds like an accusation. The doctor hears the request and hears a red flag, because that is what the doctor was taught to hear. Neither one is the enemy.
Patients and doctors should stop blaming each other for a choice that neither of them made. The choice was made by regulators who wanted a deterrent, by a manufacturer that sold one, and by a standard of care that formed around them. What we should all ask for instead is a plain answer to a plain question: is choosing Suboxone over Subutex a scientific decision or a marketing one?
Until that answer exists, I believe the decision should rest on the evidence we do have and on the person in the room. The evidence says the two work the same under the tongue. The person in the room may have a reason for one or the other, and that reason deserves to be heard rather than suspected.
Lives are at risk from opioids every day, and buprenorphine, in either form, is one of the best tools we have for saving them. The medicine is the same in both. Take the one you can take.
How does this work in my practice?
In my own practice, buprenorphine films and tablets are prescribed by telemedicine to new patients anywhere in Florida, with in-office visits available in Fort Lauderdale. Induction is done at home with phone support, and when fentanyl is involved I start with a low dose when needed.
When there is a documented reaction to naloxone or a pregnancy, the plain tablet is the right prescription, and I write it. I talked through the naloxone question years ago on an early episode of my podcast, The Rehab Podcast, and my view has not changed.
To ask Dr. Leeds about Suboxone treatment for opioid dependence and addiction, or about whether the combination or the plain tablet is right for you, 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.
