Suboxone
is a combination of two drugs – buprenorphine which is a synthetic opioid
partial agonist and naloxone a synthetic opioid antagonist.
Agonists are drug that act at a specific receptor. For example
oxycodone is an opioid agonist, as is methadone. Partial agonists
are drugs which have a partial effect at a receptor. One of the advantages of
partial agonists is safety – you can increase the dose past what would
be considered normal and not get any additional effect. Therefore it is difficult
to overdose on these drugs. Another advantage in terms of addiction is that
partial agonists are very effective at preventing recovering addicts from getting
high on other opiates – the further effect is blocked. Antagonists
have no effect at the receptor but do block active drugs from binding and therefore
block any opiate effect
Suboxone
is allowed to dissolve under the tongue – the buprenorphine is not effective
if the pill is swallowed only if it absorbs under the tongue. The naloxone is
only active if the pill was liquefied and injected – naloxone would block
any effect that the buprenorphine would have if injected. This is a safety feature.
Suboxone is used to treat addiction to other opiates, for example codeine, oxycodone, hydromorphone, meperidine, morphine and heroin. It is about as effective as methadone. It is not useful in treating an addiction to cocaine or crack, methamphetamine (speed), MDMA (ecstasy), benzodiazepines (valium and others), marijuana or alcohol.
Suboxone
is effective in reducing the craving to use opiates and the symptoms of opiate
withdrawal. Patients get a chance to get their lives back on track because they
no longer have to spend considerable time and resources to locate drugs. They
now have an opportunity to separate themselves from the people and environments
that promote drug use and other harmful activities. Suboxone can be effective
whether you inject, snort or swallow opiates. Several scientific studies have
proven that addicts on an opioid maintenance program are less likely to have
legal or medical problems and are more likely to hold down a job, stay in school
and keep their family together.
Only specially trained physicians are able to prescribe Suboxone for Suboxone Maintenance Treatment (SMT) or Suboxone Detoxification. The doctors at BMC are trained in Suboxone treatment.
How is Suboxone started?
Starting Suboxone is termed an Induction. Suboxone Induction should only be attempted by a physician trained in the procedure. Because Suboxone is a partial agonist it may put people dependent on opiates into a precipitated withdrawal. Precipitated withdrawal is a rapid onset and intense withdrawal caused by taking Suboxone when you have sufficient opiate drugs in your system. Before the induction the physician will ensure you are in a partial opiate withdrawal state and then slowly introduce Suboxone to your system over several hours. You will spend a full morning at our clinic, be reassessed at the end of the day and checked again the next morning. There is a special charge (outside of OHIP) for Induction.
How is Suboxone taken?
Suboxone is a sublingual (under the tongue) tablet taken
once a day or every other day. Initially patients must go to a pharmacy every
day to get their dose. The pharmacist will witness the doses being taken. As
they progress in the treatment program they may be allowed to take doses home
to take on their own. Likewise, initially they attend clinic twice per week.
As they progress they attend clinic less often.
How much does Suboxone cost?
Suboxone is not covered by the provincial drug plan in Ontario at this time.
If you are on social assistance, disability or over 65 methadone may be a better
choice. Depending on the dose you are stabilized at you could be paying $30
per day although this charge would decrease as you achieved carries (take home
doses) because of decreased dispensing fees.
Effects and side effects
Euphoria (feeling high) or sedation is possible if too high a dose of methadone
is taken. Typically patients feel no effect except a decreased need for opiates
- a low dose is started for safety reasons. Stabilization is usually achieved
over a few days (compared to a few weeks with methadone). During the stabilization
phase some patients experience withdrawal and may decide to continue using to
prevent these symptoms – this is usually not effective. Once stabilized
patients do not get “high” and they do not suffer withdrawal or
craving for opiates. Patients usually do not get high if they take other opiates
because Suboxone maintenance blocks the euphoric effects of these drugs –
this helps to decrease the desire to use opiates.
Suboxone is useful to prevent withdrawal because it has a long duration of action.
For most people a single dose prevents withdrawal for more than 24 hours. Higher
doses of Suboxone do not cause a high but may result in a decrease in the dosing
frequency to 48 hours. By slowly decreasing the dose over weeks or months (more
typical) patients can become opiate free without having to go through withdrawal.
Patients that are compliant with their treatment contract are never forced to
go off SMT – some stay on indefinitely.
Most people get some side effects. Most common are constipation (typical of
all opiates), dizziness or drowsiness. Withdrawal symptoms like headache, abdominal
cramps, nausea, insomnia or diarrhea may be part of the induction phase but
usually resolve once the patient is stabilized.
Taken as directed, Suboxone is very safe and does not cause long-term damage
to organs, even after several years. Some people do get elevations in their
liver enzymes which reverse once the drug is stopped. However, it is not approved
for use in pregnancy. A disadvantage of Suboxone compared with Methadone is
acute pain. It can be difficult to treat the pain of a toothache or a broken
bone. In the case of scheduled surgery, we would stop the Suboxone and treat
you with methadone until the pain has resolved.
Will I become addicted to Suboxone?
Patients taking Suboxone are already physically dependent to opioids –
stopping it will cause the uncomfortable physical symptoms of withdrawal. However,
by definition these patients are not addicted to Suboxone even though they are
physically dependent - addiction involves not only a physical need for the drug
(dependence) but several undesirable behaviors that a person develops to help
them get the drug. These behaviors might include spending money that should
go to your children, lying to your loved ones about where you are going, missing
work, breaking the law, avoiding your friends and family etc. Patients on SMT
have a steady supply of medication which blocks the need and desire for opiates
therefore the patient has no reason to continue with these behaviors –
many of which the patient is ashamed of or otherwise wants to stop. Patients
start to reform the self respect they have lost as a result of the addiction.
They are free at any time to stop the SMT if they want to or to slowly decrease
their dose of Suboxone which is the recommended approach as it is a more successful
method of staying totally off opiates. Many scientific studies have shown that
Suboxone and Methadone Maintenance remain the most successful treatment currently
available for opiate addiction. Both treatments are more effective with ongoing
drug counseling.
Suboxone Maintenance
In
Ontario patients taking Suboxone must follow the same rules with respect to
clinic visits, urine testing and restrictions in carry home doses as Methadone
patients.