A Brief Overview of Suboxone and the Treatment of Addiction
In discussing addiction and its treatment with Suboxone, it is important to briefly discuss the current understanding of addiction, as well as current attitudes and opinions. Principles of Addiction Medicine, 4th Edition, the textbook for The American Board of Addiction Medicine, states that “The modern use of opioids as a maintenance pharmacotherapy began…in the 1960s. Negative attitudes toward opioid maintenance therapy (OMT) have been common since that time among physicians, other treatment staff, patients, and the general public. These attitudes often stem from the perception that OMT is just ‘substituting one drug for another’. Rather than a simple substitution or replacement for illicit opioids, OMT involves stabilization or correction of a lesion or defect in the endogenous opioid system.” In other words, people who suffer from addiction have a genetic disease, not simply a lack of willpower or character defect. “Indeed, the initial hope of many practitioners, policy makers, and regulators was that OMT could be used to transition patients to a drug-free lifestyle and then be withdrawn. This has not proved to be the case. Studies have shown that only 10% to 20% of patients who discontinue OMT are able to remain abstinent. This range is similar to that seen with many chronic medical conditions for which control requires ongoing use of medication.”
A paper published in 1988 in the Journal of American Medical Association further supports this notion stating that the majority of addicted individuals who were simply taken off of opioids relapsed. “The treatment, therefore, is corrective but not curative for severely addicted persons.” The concept of addiction as a chronic disease is now firmly based in scientific fact, as over 100 mutations to the opioid receptor gene have been described, some resulting in severe and incurable addiction. Even as far back as 1998 the National Institute of Health supported the chronic disease model of opiate addiction and pointed to opioid maintenance therapy as the best available therapy. Advances in medication to treat opiate dependence have provided us with newer and much more effective and safer treatments over the past two decades.
The success achieved by the use of a new medication called buprenorphine (also known as Suboxone), for the treatment of opioid addicted individuals has been overwhelming. Previous abstinence-based programs had less than 20% success rates, while buprenorphine shows an 80% decrease in illicit opiate use, as well as a 50% decrease in overdose death rates. Its efficacy and long-term safety profile are also outstanding. But in spite of its tremendous success, there is a great deal of misinformation and suspicion surrounding treatment with buprenorphine. This is in part due to an unfair comparison to Methadone, the first drug used for opioid maintenance therapy. Not only is buprenorphine far safer than Methadone, with no mental impairment, but its ability to be provided through outpatient primary care physicians has allowed access to a much greater number of addicted individuals than previously possible.
The two issues that are frequently raised concerning buprenorphine are the diversion/abuse issue, and the safety issue. I’ll deal with the simplest one first, the safety issue. Simply put, people do not die from a buprenorphine overdose. By itself, due to the nature of the medication and its “ceiling effect”, it is virtually impossible to overdose on buprenorphine alone. Certainly, people have died after taking a mixture of illicit medications, but not by buprenorphine itself. Or in the words of Dr. Tim Baxter, medical director of Reckitt Benckiser, the maker of Suboxone, “Suboxone alone cannot trigger a fatal overdose.” Not only is buprenorphine essentially overdose proof, but it can cause severe withdrawal symptoms in anyone who is currently abusing opioids. There are even cases in the literature where near fatal heroin overdoses were reversed by a bystander administering a Suboxone to the overdose victim. This interference with other opioids has the added benefit of preventing anyone currently taking buprenorphine from abusing other opioids. In other words, if you are taking buprenorphine, you cannot abuse or get high from any other opioids.
The second issue, the abuse/diversion issue, is best broken down into two components; diversion for use by addicts to treat their own addiction, and abuse by kids experimenting with drugs. To again quote Dr. Baxter, “Some kids will decide, ‘Oh, this sounds like fun, we’ll have a go.’ They may try it once, but they go on to something else” due to Suboxone’s limited potential for intoxication. But also remember that kids in this age group will abuse Coricidin (street name Skittles) and Robitussin DM, both available over the counter, as a cheap way to get high. Another reason that buprenorphine is rarely abused is that if someone who is not used to taking opiates on a regular basis takes a buprenorphine, it usually results in severe nausea and vomiting, which certainly dissuades future use!
But the real issue that concerns most authorities is the illicit sale of buprenorphine to street addicts. The misconception is that addicts are using buprenorphine to get high, when in fact they are simply taking it to relieve withdrawal symptoms. Due to buprenorphines’s prolonged effects, an addict will only have to take one dose of buprenorphine every one to two days to obtain relief, as opposed to having to take multiple doses of other street drugs every 4-6 hours to stave off withdrawal symptoms. It’s simply a matter of cost effectiveness. Principles of Addiction Medicine states, “One study in the United States showed that diverted Suboxone is being used mostly for relief of withdrawal and rarely as a drug of abuse.”
So, in summary, we now have a medication that can reduce the mortality rate of the “opiate epidemic” by 50%, has an 80% success rate in reducing illicit opiate use, causes no long-term side effects including no cognitive impairment, and is overdose proof. Yet in spite of the tremendous benefits to the individual and to society, there is still a great deal of resistance to the use of this medication. This is mostly due to negative attitudes about addiction and the people who suffer from this disease. We have an incredibly effective treatment available, now we just need to overcome our hatred, prejudice and ignorance in order to make it more widely available.
Dr. Vance Shaw, MD, FASAM
Board Certified by The American Board of Addiction Medicine
March 2011, revised May 2017