Is Suboxone the right choice for treating opioid addiction? What exactly is Suboxone?

To answer this question, I would like to start out by answering the opposite question first: “What isn’t Suboxone?” People have many misconceptions about this medication that have led to stigma, limited access, and even treatment failures.

Simply clearing up some of these misconceptions can save lives. By addressing some myths and misunderstandings first, we will have a better understanding of the importance of this treatment medication.

So, let’s start out by addressing some things that Suboxone is not, and then we will get to what exactly Suboxone is. Then, you can make an informed decision about Suboxone vs other treatments for opioid dependence.

Suboxone is not a form of legal heroin.

There are people in the world of opiate addiction recovery that seem to enjoy making the false statement that Suboxone, or more accurately, its main ingredient, buprenorphine, is a synthetic form of heroin masquerading as a treatment for opioid addiction. You may be familiar with the cold stare from a member of your local 12-step group, a drug counselor, or misinformed family member, as they drop this heavy revelation in front of you.

However, Suboxone is no more a form of legal heroin than COVID-19 vaccines are filled with microchips or nanobots. Suboxone, and other buprenorphine-based meds, works in an entirely different way than heroin, or any other opioid for that matter.

Suboxone does not get patients high. It helps them to feel normal, without getting any opioid craving or withdrawal sickness. Patients who are prescribed Suboxone are able to function as if they were not addicted to opioids in the first place. Suboxone abuse is generally not an issue.

Suboxone is not trading one addiction for another.

This misconception goes hand in hand with the previous one. Suboxone treatment is definitely not trading one addiction for another addiction. While Suboxone does cause physical dependence, meaning that coming off of it requires a gradual tapering process, it does not cause addiction. Suboxone addiction is not a significant problem, if it occurs at all.

Patients who are prescribed Suboxone tend to stop acting addictively. They do not obsess over their drug of choice and they do not regularly engage in self-harming behavior.

During the course of Suboxone treatment, when it is provided for an adequate period of time, the brain has a chance to heal and recover from changes caused by addiction. This does not mean that opioid addiction cannot come back after treatment. But it does mean that a person can go through Suboxone treatment and complete it without obsessing over opioids afterwards. Patients are definitely not left with a Suboxone addiction at the completion of treatment.

Suboxone is not a popular drug of abuse.

If someone says that they know Suboxone is abused on the streets because drug dealers sell Suboxone, this is not telling the whole story. It is true that drug dealers occasionally sell Suboxone. Yet, significant studies have concluded that nearly all Suboxone sold on the streets is used by people wanting to quit opioids.

Of course, buying Suboxone from a drug dealer is not the right way to get started in treatment for opioid use disorder. Opioid Drug dealers tend to deal more in illicit opioids, including deadly fentanyl analogs. But, the point is that few, if any, people are buying Suboxone with the intention of getting high with it.

So, yes it is true that Suboxone is sometimes sold on the streets. And, it is true that people smuggle Suboxone into prisons to sell to prisoners. Yet, the important point to take away from this is not that Suboxone is a drug of abuse, but that access to this effective treatment for opioid addiction is far too limited.

Suboxone is not going to fuel a second wave of pill mills and another opioid epidemic.

There is a fear in some of the US states affected most by opioid overprescribing that Suboxone clinics will become the next pill mills. They fear citizens walking around like zombies and increased rates of overdoses.

The fact is that patients who take Suboxone are typically very alert and function well in their home and work lives. They do not get high from their medication and they typically do not show up early to the clinic asking for more Suboxone.

In some underserved areas, there have been instances of very busy Suboxone clinics. Citizens of these regions feared that a Suboxone pill mill had moved into town.

Yet, the reason for a clinic to be very busy in a rural area is that they are the only help for miles around, so people who want to recover from opioid addiction have nowhere else to turn. In urban regions where there are more doctors, Suboxone clinics tend not to be nearly so busy.

Suboxone is not the only form of medication-assisted treatment for opioid addiction.

There is more to treating opioid addiction than simply providing a Suboxone prescription. Navigating the induction period of going from street opioids to Suboxone is not always easy.

Doctors help their patients through this period by talking them through each stage and assuring them that they will get through it and they will feel better once they are stabilized on treatment. There are also medications that doctors prescribe, sometimes referred to as comfort meds, that make the opioid withdrawal symptoms more tolerable.

With the combination of counseling, coaching, motivation, and additional medications to treat withdrawal symptoms, getting through induction is not too difficult. It is possible to quit opioid medication, street heroin, fentanyl, and even methadone, and transition onto Suboxone treatment.

In addition to Suboxone and other similar sublingual buprenorphine meds, such as Bunavail, ZubSolv, and Subutex, there are other medications that doctors prescribe or dispense to treat opioid addiction. The two main alternatives for medication assisted treatment (MAT) are methadone and naltrexone.

What are the other MAT drugs, methadone and naltrexone?

Methadone is a powerful opioid drug that is dispensed from methadone maintenance clinics. Patients line up at the clinic for their daily dose and then go about their day. Methadone treatment is very effective for many patients with an opioid dependency and the induction process is easier than with Suboxone.

Patients with a heroin addiction do well with methadone maintenance when they are using heroin tainted with illicit fentanyl analogs. Because of the added fentanyl, patients sometimes find the Suboxone induction process to be difficult, so they opt for methadone treatment instead. Methadone can be started immediately after quitting heroin or fentanyl.

Naltrexone comes in the form of daily tablets and the monthly injection, Vivitrol. Naltrexone has the advantage of not being an opioid. It is purely an opioid receptor blocker, similar to naloxone. Patients and doctors do not have to worry about the prescribing regulations associated with controlled opioid medications.

One of the main disadvantages of naltrexone treatment is that the induction period is longer and more difficult than Suboxone. Rather than waiting about 24 hours, the patient must wait as long as one to two weeks between quitting opioids and starting treatment. Because of this, naltrexone is ideally started during a stay in residential rehab.

What exactly is Suboxone?

Now that we have discussed and dispelled some common myths and misconceptions, let’s talk about what Suboxone is. As you are aware already, Suboxone is a prescription medication approved as a treatment for opioid use disorder.

Suboxone is a combination medication, consisting of two active ingredients. The two ingredients in Suboxone are buprenorphine and naloxone.

Buprenorphine is the real workhorse of the two meds contained in Suboxone, doing all the work in protecting a patient from the effects of opioid addiction. Naloxone, an opiate receptor blocker, is included only as an abuse deterrent, to prevent people from injecting their Suboxone.

You might think of buprenorphine as a gardener, taking care of your prized rose garden, and naloxone as an armed guard, standing over the gardener to prevent theft and vandalism of the roses.

Do we really need an armed guard to protect the gardener’s work? Well, few people would try to steal a rose with the guard present. But, do people tend to steal from rose gardens when there is no guard?

Does naloxone help to prevent Suboxone abuse?

The fact is that there have not been studies to demonstrate the effectiveness of adding abuse deterrents, such as naloxone, to opioid medications. We do not know how much Suboxone abuse is prevented because of naloxone.

As discussed earlier, there is not much Suboxone abuse to begin with. Even street use of Suboxone is usually for the purpose of quitting another opioid.

Is the injecting of Suboxone a problem at all? While there are people who inject prescription opioids, it is not the most common method of opioid abuse. It is likely that there are people out there who liquefy Suboxone into a syringe and shoot it up, but it is very uncommon.

Most likely, anyone who tries to shoot up Suboxone has already been injecting other opioid tablets. They have refined the process of shooting up something that was not intended for intravenous use to the point that they do it out of habit.

So, is it a good idea to have naloxone present in Suboxone? While we do not know how well it is working to protect the world from Suboxone injecting people, we do know that it is relatively safe. There have been studies that have conclusively determined that adding naloxone to Suboxone does not cause problems for most patients.

Are there reasons to prescribe buprenorphine without naloxone?

Occasionally, a patient may complain of headaches or other symptoms related to naloxone. Another reason to prescribe buprenorphine without naloxone is for pregnant women. The combination of buprenorphine and naloxone is not known to be safe for the developing fetus.

Naloxone is far more useful in another setting. It is the main ingredient in Narcan, the life-saving, opioid overdose reversal nasal spray and injection.

There is some confusion over the inclusion of naloxone in Suboxone when people discuss how Suboxone works. Some people think of it as buprenorphine is the opioid and naloxone is the blocker, and that somehow treatment is provided by the combination of the two.

In fact, naloxone does nothing at all when Suboxone is taken properly. Naloxone is an active drug when taken by nasal spray or injection. When it is swallowed, it does nothing.

What is buprenorphine?

Buprenorphine is the ingredient in Suboxone that does all the work of keeping a person in treatment from having cravings or opioid withdrawal symptoms. While it is officially an opioid drug, it is really a mixed partial opioid agonist and opioid antagonist.

What this means is that, as an opioid antagonist, buprenorphine is a powerful blocker of the opioid receptor, similarly to naloxone and naltrexone. Yet, while blocking the receptors, buprenorphine also, as a partial agonist, mildly activates them.

This is in contrast to how all other opioids work. Opioids typically flood the system and bounce on and off of receptors at high speed, fully activating the receptor with each binding. This quickly leads to a downgrading of receptors and opioid tolerance.

Opioid tolerance is the reason why opioid users tend to use higher and higher doses of opioids to attempt to achieve the same high. Fortunately, tolerance is not an issue with buprenorphine.

In fact, patients are not prescribed higher and higher doses of bupe for another reason. It has a ceiling effect. Above a certain level, the effects wear off and any additional drug consumed passes through the patient’s system.

This ceiling effect also protects the patient from respiratory depression and Suboxone overdose in most cases. Buprenorphine, by being a blocker, saturates the receptors and blocks most of them, protecting the patient from further opioid effects from both other opioids and buprenorphine itself.

The unique nature of the drug makes it ideal for treating opioid dependence. While it is also an effective pain medication for some patients, it is primarly suited for the treatment of opiate addiction in an outpatient setting.

How is Suboxone taken?

The administration of a Suboxone dose is interesting. It is absorbed under the tongue. There are not a lot of sublingual manufactured pharmaceutical products.

The reason why it is taken sublingually is that buprenorphine is not an active drug when taken orally and swallowed. If a person swallows their Suboxone, it will not work.

By allowing the mucous membrane under the tongue to absorb the medication, Suboxone goes right to the bloodstream and works effectively. So, why is it not provided by injection if it must enter the bloodstream directly?

As you can probably guess, in treating addiction, it is not a good idea to provide injectable medication. Addiction experts and government officials probably would never have approved of the treatment if it involved handing the patient a vial of buprenorphine and a handful of syringes with needles.

Yet, buprenorphine was previously available as a treatment for pain relief as an injectable. It was, and possibly still is, sold as a pain medication under the brand name, Buprenex. Fortunately, it was discovered along the way that it could be administered as a sublingual strip or sublingual tablet, so injection was no longer necessary.

What Suboxone-like brands and dosage forms are available?

Suboxone is available as a film and a tablet. The official name for the current brand is Suboxone Film. Suboxone is also available as a generic buprenorphine/naloxone tablet and strip from various companies, including Dr. Reddy and Mylan.

The Suboxone film strips tend to dissolve very quickly and easily when placed under the tongue. Unfortunately, they also have a reputation of a bad aftertaste. Some people recommend coffee or a mint afterwards.

Some generic Suboxone tablets take much longer to dissolve than the strips or other tablets. While the Suboxone Film takes about three minutes to fully dissolve, some tablets can take as long as 20-30 minutes. However, most sublingual tablets are not too bad and also dissolve in just a few minutes.

What is ZubSolv?

ZubSolv is an alternate brand of buprenorphine/naloxone that has a few advantages over the Suboxone Film brand. ZubSolv is a tablet that dissolves very quickly. The company clocked the average dissolving time at about 2.9 minutes.

Another advantage of ZubSolv is taste and aftertaste. Instead of the sickly aftertaste that some patients get with Suboxone strips, ZubSolv tablets have a minty taste. Some patients prefer the fast-dissolving, minty taste of ZubSolv vs Suboxone.

What is Bunavail?

Bunavail is another brand similar to Suboxone. The main difference with Bunavail is that it is intended to stick to the inner cheek inside the mouth rather than under the tongue. Otherwise, it works similarly. Bunavail has never caught on in popularity compared to other brands.

Still, Bunavail is an effective alternative to Suboxone and ZubSolv as a treatment for opioid addiction. Whether you are dealing with a pain medication dependence after being treated for chronic pain, or a street opioid addiction, Bunavail is a good option for medication assisted treatment.

Are there other ways to get buprenorphine for opioid use disorder treatment other than sublingual tablets or strips?

There are other forms of buprenorphine used for opioid addiction treatment. Some of the brand names are Sublocade, Brixadi, and the now-discontinued Probuphine.

Sublocade is manufactured by Indivior, the same company that makes Suboxone Film. Sublocade is a monthly injectable form of buprenorphine. It is a subcutaneous buprenorphine injection that releases gradually throughout the month.

Brixadi is an alternate subcutaneous buprenorphine injection that has some advantages over Sublocade. Brixadi comes in more dosages, it does not have to be kept in at cold temperatures, and it can be used weekly or monthly.

Unfortunately, Indivior has blocked the full FDA approval of Brixadi in the US. However, Brixadi is available currently in other countries.

Probuphine was a six-month buprenorphine implant, similar to Norplant, a long-term birth control implant. Probuphine consisted of four rods that the doctor would surgically implant in the patient’s arm. The FDA had approved it for up to two years of use by implanting a new set of rods every six months and alternating arms.

Due to lack of use, the company withdrew Probuphine from the market. There were risks that deterred doctors and patients from choosing Probuphine, including a risk of infection, nerve damage, scarring, and migration of the implanted rods, making it difficult to find and remove them.

What strengths is Suboxone available in?

Suboxone is manufactured in the following strengths: 2 mg, 4 mg, 8 mg, and 12 mg. In most cases, pharmacies only carry the 2 mg and 8 mg Suboxone films. The 8 mg strength is the most commonly used.

When a company only makes limited dosages, the intention is for doctors to prescribe combinations of the available dosages to add up to what is needed. For example, if a doctor wants to reduce a patient from 8 mg to 6 mg, they might prescribe a 4 mg and 2 mg, or three of the 2 mg.

Unfortunately, this kind of prescribing can lead to dosing errors, since patients must keep track of taking the prescribed combination. And, there are sometimes issues with insurance coverage and cost.

For example, three 2 mg Suboxone strips is more expensive than a single 8 mg strip. This is not conducive to a patient reducing their Suboxone dosage because the cost goes up as they cut back on their medication.

Another issue is the fact that 2 mg is the lowest available dosage. When a patient is being tapered to a lower dosage by their doctor with the intent of completing treatment, 2 mg is often far too high a dose to quit the medication because of Suboxone withdrawal.

How does a patient reduce below 2 mg? Should they cut the Suboxone films or tablets in half or quarters? The manufacturer states in the literature that Suboxone should not be split.

In Australia, there is a dosage of 400 mcg, which is a step down from 2 mg. Unfortunately, we do not have this in the US.

Another way to reduce below 2 mg is to use a compounded form of buprenorphine. There are pharmacies that manufacture compounded troches, which dissolve under the tongue.

These troches can be customized to the precise dosage required for the patient. They are ideal for tapering and completing Suboxone therapy. Interestingly, the FDA has been known to put pressure on compounding pharmacies to not produce compounded buprenorphine. Why would they do this? Is there a conspiracy to keep patients from being able to easily taper off of Suboxone?

How long should Suboxone therapy last?

Early on, when Suboxone was relatively new, there were two schools of thought. Some doctors and addiction experts believed in fast tapering, where Suboxone was used over a period of one to two weeks to detox a patient off of opioids.

The other method of treatment was long-term maintenance, where Suboxone was prescribed for a period of at least several months and up to multiple years. It turns out that long-term maintenance is the ideal way to treat opioid addiction, with the ideal time period being at least one year.

Short-term use, as in fast-tapering, still used by detox centers, is not only less effective, it can be harmful to the patient. Patients who are quickly detoxed off of opioids and Suboxone are left with their opioid addiction, still strong and intact.

After being detoxed, many patients go out and eventually relapse because they still have opiate cravings. Long-term treatment gives the patient time to recover from opioid addiction and to get their life back together.

Everyone is different, so different people will benefit from different lengths of therapy. Some people will benefit from multiple years of treatment. There is no judgement associated with how long a person requires treatment. There is no competition to see who can finish their treatment plan more quickly.

What is the next step in getting started with Suboxone treatment?

There are different types of Suboxone programs to meet the needs of different patients. There are methadone maintenance-like treatment programs with daily visits and there are family doctors who treat patients monthly.

Additionally, there are telemedicine programs that provide online suboxone support. Of the office-based and telemedicine options, one of the most effective options is concierge Suboxone treatment.

With concierge, the patient has direct access to the doctor 24/7, with around the clock support. When evaluating a medication-assisted program that provides Suboxone, ask if they provide this service.

Are you able to contact your doctor directly if you have questions, problems, or just need motivation to get through a difficult period? Some programs do not offer direct support from the doctor. In fact, some programs do not even provide doctors at all. A nurse gives out prescriptions, and even less trained staff provide whatever support is needed.

Fortunately, there are many options and treatment is becoming more accessible and available in more regions all the time. Most important are the government-funded programs that are initiated in hospital ERs.

These funded pilot Suboxone programs start patients on treatment from the time of overdose or other adverse event that takes a person to the ER. Then, local clinics continue treatment.

In many cases, these programs are available at little or no cost to patients who cannot afford treatment. This is critical, that patients who cannot afford to see a doctor do not fall through the cracks.

How do I find a Suboxone doctor around me?

To find a doctor in your area, you might use the SAMHSA treatment locator or the website, treatmentmatch.org. These resources make it easy to locate local providers of buprenorphine treatment in your area that match up with your individual needs.

If you are looking for concierge Suboxone telemedicine services, and if you are in the state of Florida, you are welcome to reach out on this website, using our contact form. While space in our program is limited, we do have spaces that become available on a regular basis.