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January 22, 2019

Suboxone vs Subutex: Breaking it Down

Suboxone and Subutex are the brand names for two buprenorphine medications to treat addiction to opiate substances, such as illicit heroin and prescription opiates (natural, semi-synthetic and synthetic). Suboxone contains naloxone and buprenorphine, while Subutex only contains buprenorphine. Beyond medication content differences, though, there are other differences in when and how they’re used in treating opiate addiction.

Both Suboxone and Subutex are classified as narcotics under the Controlled Substances Act, meaning they have the potential for misuse, diversion and abuse. The Drug Enforcement Agency (DEA) closely monitors street diversion of Suboxone and Subutex.

WHAT IS MEDICATION-ASSISTED TREATMENT

MAT is a treatment approach that combines the use of FDA-approved medications and counseling and behavioral therapies. MAT is instrumental in helping address America’s escalating opiate problem.

  • Methadone is a synthetic opiate, an agonist, that makes withdrawal symptoms less severe. In higher doses, methadone can block the effects of opiate-containing drugs and heroin. The only way to get methadone legitimately is at an inpatient or outpatient treatment program (OTP) certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and registered with the DEA, or when administered to a person hospitalized in an opiate emergency.
  • Naltrexone is an antagonist. It is both non-narcotic and non-addictive, and works to block opiate receptors in the body so they cannot be activated. When a person is on naltrexone, he or she will be unable to feel the effects of opiate drugs they take. An injectable and long-lasting drug, naltrexone is approved to prevent relapse in those with opioid use disorder after they have completed opiate detox and have been opiate-free for 7-10 days.
  • Buprenorphine, approved by FDA in 2002, is a partial agonist that helps combat withdrawal symptoms. While it is true that buprenorphine can create some of opiates’ effects and side effects, such as euphoria and respiratory depression, those effects are generally milder than the effects of drugs like heroin and methadone, both full-agonist drugs. The only way to get buprenorphine legitimately is through specially trained physicians in intensive outpatient and inpatient treatment centers, as well as by prescription from specially trained doctors in office settings, with prescriptions filled at pharmacies. In addition, in order to prescribe buprenorphine, doctors must sign a waiver granted by the DEA.

SUBOXONE

Suboxone is the brand name of a combination drug containing both naloxone and buprenorphine. Naloxone is a drug used to overcome the effects of an opiate overdose. Naloxone also helps protect against misuse. Suboxone is placed under the tongue and allowed to dissolve. While this is the correct way to take the medication, if a person injects Suboxone, the naloxone in it gets into the bloodstream, which blocks buprenorphine’s positive effects and causes the onset of opiate withdrawal.

HOW SUBOXONE IS USED IN TREATMENT

Suboxone is used as an evidence-based, short-term treatment for OUDs, most often prescribed for those undergoing initial opiate detox. How long Suboxone medication continues following opiate is determined by the treatment team on the basis of progress made during detox, other indications that MAT should continue, and other needs of the client specific to his or her diagnosis.

A report issued by the Maine Health Data Organization in December 2018 listed Suboxone as the second most-prescribed prescription drug in the state, right behind a generic blood pressure medication. Suboxone’s high rate of prescriptions in the state highlights the severity of the opioid crisis there and the use of FDA-approved medications to treat opioid addiction.

Suboxone Not Recommended for Long-Term Use

It’s important to note that while Suboxone is an effective short-term medication for OUDs, it isn’t recommended for long-term maintenance, as research shows it can have negative consequences and unintended repercussions on the brain. Some of these include:

  • Anxiety
  • Depression
  • Decreased coordination
  • Confusion
  • Feeling lost
  • Disorientation
  • Suicidal thoughts

One study published in PLoS One found a “significantly flat affect” among long-term Suboxone clients, compared to members in Alcoholics Anonymous (AA) groups and the general population. They were less aware of being happy, anxious or sad. This was echoed in a later study that found “significant alteration in mood and emotion” with long-term Suboxone use and urged caution in the medication’s use in long-term maintenance. Another study recommended considering Suboxone’s long-term toxicity and the potential for anti-reward and relapse.

Other risks and dangers of long-term Suboxone use include overdose, allergic reaction, hepatitis, adrenal and androgen insufficiency, and serotonin syndrome.

Formal Treatment Following Suboxone Detox

Since detox alone is insufficient to prevent relapse, after initial detox, the client typically begins the second phase of treatment, generally known as the formal treatment program. Treatment includes ongoing counseling, both individual and group, introduction to support and 12-step groups, behavioral therapies, social support and other innovative and research-backed treatment approaches. The goal of formal treatment is to help the individual learn how to live a drug-free life in recovery by equipping him or her with necessary tools and skills proven effective to maintain long-term sobriety.

SUBUTEX

Subutex is the brand name of buprenorphine, another medication used to treat OUDs. Subutex, a synthetic partial opioid agonist, contains only buprenorphine. This is in contrast with Suboxone, which contains buprenorphine and naloxone. Despite its benefits in helping people overcome dependence on opiates, however, Subutex can be addictive, since it is still an opiate. Like Suboxone, Subutex is administered whole and placed under the tongue, where it is allowed to dissolve. No eating or drinking should occur until the Subutex is completely dissolved.

HOW SUBUTEX IS USED IN TREATMENT

Subutex is used in MAT for opiate dependence and in the treatment of withdrawal symptoms from opiates such as heroin, Oxycontin and other narcotic painkillers, and methadone. Subutex is typically used in the induction from heroin, and later the user may be transitioned to Suboxone. In the brain, Subutex stimulates some of the same areas that heroin and morphine do, which results in similar effects of euphoria, pain relief and sedation. What’s different with Subutex, though, is that the FDA-approved medication causes less respiratory depression and sedation and has not been shown to cause significant cognitive or motor skills impairment.

Just as Suboxone and methadone block the effects of heroin, Subutex ensures that it is impossible to get high from heroin when taking the medication. Taking higher doses of Subutex (above 32 mg) doesn’t produce any increased sense of sedation, euphoria or analgesia. This is the ceiling effect of Subutex. What can happen when a person takes high Subutex doses, however, is the onset of precipitated opiate withdrawal symptoms. Furthermore, overdose risk greatly increases in those who misuse Subutex by injecting the drug and those who’ve attempted to stop Subutex cold turkey and then went back to taking high doses.

Formal Treatment Following Subutex Detox

Just as detox from Suboxone alone is not enough to prevent relapse, clients who’ve undergone Subutex detox aren’t adequately equipped – physically or psychologically – to return to their normal life. If they do, they risk almost certain relapse. The recommended course of action after Subutex detox is to enter formal treatment that has been designed to meet the individual’s needs and wants. As with treatment for other OUDs, Subutex treatment programs generally include ongoing individual and group counseling, participation in 12-step and support groups, behavioral, alternative and holistic therapies and additional social support.

OVERDOSE RISKS FOR BOTH SUBOXONE AND SUBUTEX

Severe negative side effects include overdose, resulting in unconsciousness, severe respiratory depression and death. This is especially risky for those who inject Suboxone or Subutex and take tranquilizers or sedatives or drink alcohol. Life-threatening situations can develop from taking excessive amounts of oral Suboxone or Subutex in combination with other opiate medications, certain antidepressants, sedatives, tranquilizers or alcohol.

According to statistics published by the National Institute on Drug Abuse (NIDA), using Centers for Disease Control and Prevention (CDC) CDC Wonder, there were more than 72,000 drug overdose deaths estimated in 2017. The report said the sharpest increase occurred among deaths related to fentanyl and fentanyl analogs (synthetic opioids), with nearly 30,000 overdose deaths, a 22-fold increase in fentanyl-related deaths from 2002-2017.

OTHER ADVERSE REACTIONS TO LONG-TERM SUBOXONE AND SUBUTEX USE

Long-term use of Suboxone and Subutex has resulted in some additional adverse reactions, according to the full prescribing issued by the drug manufacturers. These include:

  • Adrenal Insufficiency
  • Androgen Deficiency
  • Anaphylaxis
  • Serotonin Syndrome

Keep in mind that the decision to taper off from Suboxone or Subutex treatment is one that should only occur as part of a comprehensive treatment plan. The treatment team will make the decision when the time is right for the patient to receive a slightly lower dose while also remaining cognizant of minimizing withdrawal cravings. Concerns about opiate relapse should be discussed with the doctor and the treatment team.

For more about Suboxone, Subutex, addiction and recovery, check out these articles:

  1. Dangers of Long-Term Suboxone Treatment
  2. Suboxone Detox – Withdrawal Symptoms and Timeline
  3. Will Suboxone Show up in a Drug Test? [link to article after published]
  4. Methadone Detox – Withdrawal Symptoms and Timeline
  5. Prescription Opiate Detox: What to Expect from Withdrawal and Recovery
  6. Addiction Recovery Tips: Key Components of a Healthy Recovery Lifestyle
  7. Why Medication-Assisted Treatment is Important for Opiate Addicts in Early Treatment

Sources:

Maine Health Data Organization. “MHDO Prescription Drug Reports.” Retrieved from https://mhdo.maine.gov/tableau/prescriptionReports.cshtml

Molecular Neurobiology. “Can the chronic administration of the combination of buprenorphine and naloxone block dopaminergic activity causing anti-reward and relapse potential?” Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3682495/

National Drug Intelligence Center. “Intelligence Bulletin.” “Buprenorphine: Potential for Abuse.” Retrieved from https://www.justice.gov/archive/ndic/pubs10/10123/index.htm

National Institute on Drug Abuse. “Overdose Death Rates.” “National Overdose Deaths: Number of Deaths Involving Opioids.” Retrieved from https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

PLoS One. “Long Term Suboxone Emotional Reactivity As Measured by Automatic Detection in Speech.” Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706486/

RXList. “Subutex.” Retrieved from https://www.rxlist.com/subutex-drug.htm#description

Suboxone.com. “Important Safety Information.” Retrieved from https://www.suboxone.com/Content/pdfs/SuboxoneISI.pdf

U.S. Department of Health and Human Services. “What is the U.S. Opioid Epidemic?” Retrieved from https://www.hhs.gov/opioids/about-the-epidemic/index.html

Washington Times. “How medication treats opioid addiction.” Retrieved from https://www.washingtontimes.com/news/2018/dec/26/opioid-addiction-treatment-includes-other-drugs/v

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