Suboxone
Suboxone Overview

Suboxone is the brand name of a drug combination containing buprenorphine and naloxone. It was approved by the Federal Drug Administration (FDA) in 2002 for the treatment of opioid dependence. Suboxone is available as sublingual films that are dissolved under the tongue (sublingual) or inside the cheek (buccal).

Opioid Addiction Statistics

The Centers for Disease Control (CDC) has described the current pattern of opioid use in the United States as an “opioid epidemic.” Below are some of the CDC’s harrowing statistics regarding the opioid epidemic in the United States.2

  • From 1999 – 2017, nearly 400,000 people have died from an opioid overdose (prescription painkillers or illegal drugs such as heroin).
  • The rate of opioid deaths has increased dramatically, with six times as many deaths due to opioid overdose in 2017 than in 1999.
  • Opioid overdose is responsible for approximately 130 deaths every day in the United States.

The Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that in 2017 approximately 2.1 million people in the United States had abused or were dependent on opioids.3 Many of those dependent on opioids are prescribed Suboxone to treat their dependence.

Who Can Prescribe Suboxone?

Not all prescribers can prescribe Suboxone. Under the Drug Addiction and Treatment Act (DATA), only qualifying prescribers may prescribe Suboxone after completing a special training program. To find a Suboxone prescriber near you, visit the SAMHSA buprenorphine practitioner locator.

How Suboxone Works in the Brain

Opioids are drugs that bind to opioid receptors in the brain. They are addicting because they mimic endorphins, our body’s natural “feel good” chemicals. There are three main types of opioids in terms of how they interact with opioid receptors: agonists, partial agonists and antagonists.

 

 How it WorksExamples
Agonist

Higher dose leads to a stronger effect

 

Heroin, morphine, hydrocodone, fentanyl, methadone
Partial Agonist

Higher dose leads to a stronger effect until a ceiling is reached

 

Buprenorphine
AntagonistBlocks the effect of opioidsNaloxone, naltrexone

 Addicting opioids such as heroin, morphine, hydrocodone, oxycodone and fentanyl are all opioid agonists, drugs that fully activate the opioid receptor. As the dose of an agonist increases, so does the effect.

Buprenorphine, one of the two ingredients in Suboxone, is a partial agonist. As the dose of buprenorphine increases, so does the effect, but only until a ceiling is reached. As shown on the graph below (orange is Suboxone), as the dose increases, the effect increases steadily until a plateau is reached. Once the plateau is reached, the effect remains the same even when the dose increases. This is an important property of buprenorphine, as a user is less likely to abuse it by taking higher doses. Once the plateau is reached it is impossible for the user to feel “higher” by taking more of it.

Why Does Suboxone Contain Two Drugs?

In addition to the opioid buprenorphine, Suboxone also contains the opioid antagonist known as naloxone. When naloxone is taken, it blocks the effects of opioids. If someone who is not dependent on opioids takes naloxone, there will be no effect. However, if someone dependent on opioids takes naloxone, they will immediately suffer painful withdrawal symptoms as the naloxone flushes the opioids out of their system.

This may seem very strange at first. Why would a drug used to treat opioid addiction contain an ingredient that can cause painful withdrawal symptoms? The reason is due to naloxone’s bioavailability. Bioavailability is the percent of a drug that reaches the blood stream to exert an effect. The bioavailability of naloxone is different depending on how it is taken.

Effect of Naloxone
Dissolved under tongue/cheekInjectedSnorted
NaloxoneNo effectStrong effectStrong effect

As shown in the table above, when naloxone is dissolved under the tongue or inside the cheek (the way Suboxone should be taken), it has no effect. If naloxone is injected or snorted, it exerts its full effect as an opioid antagonist, immediately producing painful withdrawal in an opioid-dependent individual.

Because naloxone causes no effect when taken as prescribed but can cause painful withdrawal when it is abused, it is added to Suboxone to deter drug abuse and ensure it is taken exactly as prescribed.

How to Use Suboxone

Suboxone is supplied as a sublingual film that can either be dissolved under the tongue or inside the cheek. The guides below should be followed on how to take Suboxone either sublingually or buccally.

Sublingual Administration (under the tongue)

  • Drink water to moisten your mouth.
  • Hold the film between two fingers by the outside edge.
  • Place the film under the tongue, close to the base of either the left or right side. If taking two films at a time, place each film on the opposite side.
  • Keep the film(s) in place until they have dissolved

Buccal Administration (inside the cheek)

  • Hold the film between two fingers by the outside edge.
  • Place the film on the inside of either the left or right cheek. If taking two films, place each film on the side of each cheek.
  • Keep the films in place until completely dissolved.

A burning sensation while the films are dissolving is normal, however do not take Suboxone if you are allergic to buprenorphine or naloxone. Each Suboxone prescription obtained at a pharmacy comes with a medication guide containing important information on how to use the drug.

 Side Effects

Because Suboxone contains buprenorphine, an opioid, the user may experience side effects consistent with that of other opioids such as:

  • Sedation
  • Dizziness
  • Nausea and vomiting
  • Constipation
  • Respiratory depression
Overdose

The most dangerous side effect of Suboxone is respiratory depression, defined as shallow, labored breathing. Respiratory depression is distinct from breathing problems caused by asthma or COPD. Using a rescue inhaler will not treat respiratory depression caused by an opioid overdose. Because respiratory depression can result in death if not managed quickly, it is considered a medical emergency.

In cases of respiratory depression due to Suboxone overdose, the drug Narcan is used. Narcan is a nasal spray containing naloxone, the same opioid antagonist found in Suboxone. Narcan works within minutes to restore normal breathing and is available without a prescription in most states including California.7

It is important to note that while Suboxone contains the same ingredient as Narcan, the naloxone contained in Suboxone films is not effective at treating respiratory depression, only the Narcan nasal spray should be used.

Abuse Potential and Signs of Suboxone Abuse

Despite the buprenorphine in Suboxone being only a partial agonist, it is an opioid nonetheless and can still make the user feel high. Consequently, Suboxone carries the potential for abuse, though not as significant as opioids such as hydrocodone, oxycodone and fentanyl.

Because individuals being treated with Suboxone are already undergoing treatment for opioid dependence, one of the most telling signs of an individual abusing Suboxone is running out of it too soon.

By law, Suboxone can only be dispensed at a pharmacy for a 30-day supply each time it is picked up. If a user takes more than what is prescribed, they will inevitably run out of Suboxone before their next refill is due. Frequent attempts to refill Suboxone early may indicate that Suboxone is being abused.

Withdrawal

If a dose of Suboxone is missed, or the dose is reduced too quickly, a Suboxone user may experience symptoms of opioid withdrawal such as:

  • Diarrhea
  • Muscle aches and cramps
  • Feeling hot or cold
  • Insomnia
  • Runny nose
  • Drug craving

If Suboxone is discontinued completely, withdrawal symptoms may begin 12 hours following the last dose and peak within three days. Physical symptoms will begin to subside after 1-2 weeks, though lingering depression and drug craving may continue for weeks or months.

Suboxone should not be discontinued suddenly (“cold turkey”), as it increases the probability of experiencing withdrawal symptoms. Rather, Suboxone should be tapered by slowly decreasing the dose over time, allowing the body to adjust to lower doses of the opioid.

Suboxone Schedule – Induction, Maintenance, Taper

The timeline for treatment with Suboxone follows three main stages: induction, maintenance and tapering.

Induction – The initial period of Suboxone therapy is called induction, the goal of which is to safely suppress the symptoms of opioid withdrawal as quickly as possible with therapeutic doses of Suboxone.

Maintenance – Once induction is complete and withdrawal symptoms are adequately controlled, a maintenance period begins where a steady dose of Suboxone is taken to prevent the emergence of withdrawal symptoms.

Tapering – Once withdrawal symptoms are adequately controlled with a maintenance dose, the dose of Suboxone is tapered (reduced) over time until Suboxone can be safely discontinued.

The length of a Suboxone taper will depend on the individual. Some factors that may affect the length of a taper include:

  • The dose of the opioid being abused
  • How long the opioid was abused for (long term vs short term)
  • Ability to tolerate Suboxone dose reductions
Seeking Out Help

Drug addiction is a difficult disease to manage alone; it is highly recommended that an individual addicted to opioids seek help in the management of their condition. An addiction specialist can recommend several options such as Suboxone to manage withdrawal symptoms and help along the path to stopping drug abuse.

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