FAQs about Suboxone

The active ingredient of Suboxone is buprenorphine. For the purposes of this FAQ, the term Suboxone and buprenorphine will be used interchangeably. Buprenorphine is a partial agonist that works at the opiate receptor. It stimulates the opiate receptor sufficiently to stop withdrawals and cravings towards opiates. Because it is a partial agonist, it does not cause the unwanted effects of respiratory depression or overdose typical of complete agonists such as hydrocodone, oxycodone, heroin or methadone. There is also no tolerance (tolerance is defined as progressive dose increases over a period of time) and there is a ceiling effect (there is no difference between taking 20 mg of buprenorphine vs 30 mg of buprenorphine per day). The lack of a tolerance and the presence of a ceiling effect allow buprenorphine to be taken safely in the comfort of your home.

Buprenorphine is taken sublingually or under the tongue. It also absorbs from the mouth or the oral mucosa. It is important to keep the medication in your mouth, under the tongue, as long as possible. Buprenorphine does not absorb in the stomach or intestines. If it is swallowed, it will pass into the stool and will not work in helping with the withdrawals or the cravings.

When transitioning from opiates to buprenorphine, the patient should be in at least moderate withdrawal before taking their first dose of buprenorphine. There is the COWS scale that could be used to determine the presence of moderate withdrawal. A general rule of thumb is that one should not start buprenorphine until the patient starts to experience diarrhea. Failure to wait until moderate withdrawal before starting buprenorphine can lead to precipitated withdrawal which is defined as a sudden onset of withdrawal symptoms. The problem with precipitated withdrawal is that it leads patients to conclude that buprenorphine is ineffective. The treatment for precipitated withdrawal is administering small doses of buprenorphine (2 to 4 mg) every hour until the withdrawal symptoms have resolved.

A cure is defined as a one-time treatment, after which the treatment course is completed, the condition or the disease is gone. Antibiotics cure pneumonia. Once the antibiotic course is completed, pneumonia is usually gone and does not usually come back. Buprenorphine does not cure opiate addiction the way antibiotics usually cure pneumonia. Buprenorphine is basically a safe, legal and inexpensive substitute for dangerous, illegal and expensive opiates. When buprenorphine is stopped, the cravings for opiates come back.  However, unlike opiates such as hydrocodone or oxycodone, there is no tolerance with buprenorphine. Therefore, taking buprenorphine is not exactly switching from one addiction for another.

It is very safe. Overdose deaths in patients who take buprenorphine on a regular basis, under the tongue (as opposed to intravenous injection), without taking anything else such as high doses of benzodiazepines or cocaine, almost never occur. 

The people who die of an overdose while taking buprenorphine either inject it intravenously or use benzodiazepines, cocaine or methamphetamine.  A forensic study from France, published in 2002, found that all the fatalities in patients who had buprenorphine in their blood were due to either IV injection of buprenorphine or using either sedatives such as benzodiazepine such as alprazolam or diazepam or stimulants such as cocaine.

Buprenorphine was first approved in 2002. Since then, there have been millions of buprenorphine prescriptions. If there were a significant side effect such as liver toxicity, buprenorphine would have already been pulled off the market. To put things in perspective, non-steroidal anti-inflammatory medications such as Ibuprofen cause 16,500 deaths every year due to gastrointestinal bleeding.

In general, serious interactions with benzodiazepines and buprenorphine do not usually occur unless the dose of alprazolam (or equivalent) is more than 2 mg per day. The risk of an interaction is also lower if the patient has been on the same benzodiazepine dose for a long time.  With that being said, sometimes patients do not disclose to their physician how much benzodiazepines they are taking. They may also have a co-morbid addiction towards benzodiazepines. It is important for patients to be honest with their physicians. Benzodiazepine addiction is managed entirely separately from opiate addiction and unlike opiate dependence, may often require inpatient detoxification.

Buprenorphine results in an 80 percent reduction in the risk of overdose death on a population level. The risk of death is even lower in people who take buprenorphine on a regular basis.

The main side effect is constipation. The constipation can be managed by taking a daily stimulant laxative such as Dulcolax or Sennakot in combination with daily MiraLAX. Buprenorphine also may cause insomnia. The other problem with Suboxone is that it unmasks preexisting anxiety. A lot of patients who became dependent to opiates started by self-medicating with opiates. The opiates calmed them and made their anxiety temporarily go away. Once the opiates are gone, the underlying anxiety sometimes manifests itself. Some patients may have to get on an anti-depressant or an anti-anxiety medication.

Going back to the question on safety, if this medication were unsafe, the FDA would have already pulled it off the market. Two decades of safety data is more than sufficient to usually detect if there is a serious problem. The other question is what is the alternative? If the alternative is relapsing every few months to opiates, there is no doubt that buprenorphine is the best option. There are many patients who have lost their most productive years struggling to. How much better would their lives have been if they just took the medication on a daily basis?

About 5% of men on Buprenorphine have a decreased sexual desire. This is sometimes erroneously attributed to low testosterone. These patients sometimes go to a low testosterone clinic where they are almost always diagnosed as having low testosterone even though their testosterone is normal.  Unfortunately, it’s the medication. If the problem starts to interfere with their relationships, they may have to stop the medication altogether.

Buprenorphine, the active ingredient of Suboxone, by partially stimulating the opiate agonist, decreases the cravings and obsession to opiates. Buprenorphine also blocks external opiates from binding to the receptor. Vivitrol on the other hand just blocks opiates from binding to the receptor but there is no stimulation. Thus, there is not much of a decrease in cravings. The other important aspect of vivitrol is that one has to go through the full withdrawal from opiates before starting Vivitrol. Vivitrol is also more expensive.  Please see the nytimes article: https://www.nytimes.com/2017/06/11/health/vivitrol-drug-opioid-addiction.html.

Suboxone in some cases may help with pain. But it is not guaranteed. Some patients with chronic back pain may have breakthrough pain while on Suboxone and may need to go see their pain management doctor again. Patient must know that if they are being prescribed Suboxone for pain, their diagnosis code will be F11.20 or opiate addiction. Prescribing Suboxone for any other indication other than addiction is illegal. Also, their pain management doctor may not want to see them anymore after they started Suboxone. When considering all these facts, it’s probably best for patients who have chronic pain on prescription opiates and want to switch to buprenorphine to request their pain management physician to start them on a buprenorphine patch. Addiction or Suboxone doctors do not prescribe buprenorphine patches.

This is a two-part question. The first question is: should a patient come off of Buprenorphine in the first place? If they have no significant side effects and their history is notable for opiate use which resulted in significant consequences (job loss, marriage fell apart, kids were taken away, legal problems, bankruptcy, tax debts, hepatitis C, prior overdose, intravenous use, etc), it is probably best that these patients stay on buprenorphine for a long time, possibly even forever, or until there is a better treatment for opiate addiction.

One of the common reasons why patients want to come off Buprenorphine is because they feel hooked. They have to continuously spend their hard-earned money on something that is beyond their control. There is also this continuous worry about whether they will have problems seeing their physician or have their medication filled at the pharmacy. To deal with these problems, think of opiate dependence as a chronic illness that does not go away. Find physicians who are very supportive and always available! Keep on changing your physician until you find the right one!

Now if one must, for valid reasons, come off buprenorphine, it is important to know that the risk of relapse and possible overdose is high after coming off Buprenorphine. It is also important to know that the underlying opiate addiction has not gone away. In this clinic’s experience, patients start to experience anxiety as they taper down from their Buprenorphine. If patients find that they are using benzodiazepines or increasing their alcohol intake, it probably is not a good idea to come off buprenorphine. The patients who are successful at tapering go very slowly. It is fairly easy to get to 4 mg per day within the first two weeks. After being at 4 mg, the dose should be tapered over a the next four months from 4 mg down to 0.