When buprenorphine was approved for prescription use by the Food and Drug Administration (FDA) in 2002, the drug had been widely used in Europe to help people struggling with heroin addiction. In the US and Canada, methadone had been the medication of choice, but that long-acting opioid agonist was showing signs of becoming a substance of abuse. Since buprenorphine’s approval, drug companies developed two prescription versions: Subutex, which is pure buprenorphine (now discontinued), and Suboxone, a combination of buprenorphine and naloxone.
Buprenorphine is a partial opioid agonist, meaning it binds to the opioid receptors in the brain, just like oxycodone or heroin; however, when taken as directed and at prescribed doses, buprenorphine prevents other opioids from binding to these receptors, stays on them for a long time, and does not induce euphoria. However, because buprenorphine does have some effect on the brain, some people abused the drug in large doses or by injecting it intravenously to get a rapid high. Adding naloxone, an opioid agonist, was supposed to prevent abuse by stopping buprenorphine from binding to opioid receptors in the brain if the drug was not taken as prescribed. Instead, naloxone would bind to those receptors, forcing the person to experience withdrawal symptoms.
Trading One Addiction for Another?
Many critics have suggested that medication replacement drugs, like buprenorphine and methadone, simply trade one addiction for another. The National Alliance of Advocates for Buprenorphine Treatment (NAABT) states that treating an addiction to heroin, fentanyl, or prescription painkillers with a slow Suboxone or buprenorphine taper does not continue the problem of addiction. While people who use Suboxone as prescribed develop a physical dependence on this drug, they also have a physical dependence on their previous opioids, and the point of Suboxone is to allow the person to feel normal, attend rehabilitation and therapy to understand the compulsive behaviors of addiction, and make lasting changes to avoid heroin or prescription painkiller abuse. While the person undergoes this process, they take Suboxone or another buprenorphine medication, with a doctor’s supervision. This eases withdrawal symptoms, helps them avoid relapse, and allows them to slowly taper their body off dependence on any opioid or partial opioid agonist.
However, medical studies since the 1970s have shown that buprenorphine has abuse potential. A 2011 report published in Current Drug Abuse Reviewslists several studies that show the drug’s efficacy in treatment for opioid use disorders but also highlights the substance’s documented potential for intoxication in people who have no or little existing tolerance for opioid drugs. Studies highlighted in the article show that buprenorphine also has positive reinforcement properties, like other opioids, meaning it impacts the brain’s reward system and releases neurotransmitters like serotonin, which are associated with elevated mood. Further information in the article found that, in areas in Europe and Asia that did not have easy access to heroin, buprenorphine became a substance of abuse instead.
In 2008 alone, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported 15,700 physicians licensed to prescribe buprenorphine, Subutex, and Suboxone. There were an estimated 3.5 million prescriptions that year for either Suboxone or a buprenorphine medication. With millions of prescriptions for this partial opioid agonist in the US, some of those are diverted or abused nonmedically.
Signs of Suboxone intoxication may look like other opioid intoxication and can include:
- Altered mental status
- Poor judgment
- Pinpoint pupils
Why Suboxone Is Abused
There are a number of reasons why Suboxone has become a substance of abuse. As it is diverted into illicit markets, people who do not have a tolerance for opioids may take the drug to get high. Doctors undergo minimal training required by the federal government to prescribe Suboxone and other buprenorphine drugs, allowing them to care for up to 100 patients at a time; for many physicians and general practitioners, this is not enough time with each patient to make sure they are taking Suboxone as prescribed. Some doctors, according to a New York Times report, take only cash because of inconsistent healthcare coverage, fueling what could become the new pill mill epidemic. In fact, some of the doctors entering this field have been charged with running prescription pill mills in the past; the Times found that of 12,780 buprenorphine doctors listed nationally in 2013, at least 1,350 had faced sanctions, including excessive narcotics prescribing, insurance fraud, or practicing medicine while impaired.
Additionally, a large number of people in prison abuse Suboxone or generic buprenorphine because they are less able to get heroin while incarcerated. Because Suboxone comes in filmstrip form, it is easier to sneak in through letters or cards.
While it is not easy to find, it is frequently diverted. The Department of Justice (DOJ) noticed diversion problems with Suboxone as far back as 2004, a mere two years after buprenorphine was approved by the FDA. The department noted that people who abused Suboxone were more likely to struggle with addiction to low doses of narcotics and that people were successfully snorting it without naloxone preventing their high. The DOJ also noted that mixing buprenorphine and methadone enhanced the overall opioid euphoria, while mixing buprenorphine with heroin did not increase the high associated with either drug.
Side effects from abusing Suboxone include:
- Stomach pain
- Trouble sleeping or staying asleep
- Loss of appetite
- Low energy
- Trouble breathing
Abusing Suboxone can cause liver damage, changes in blood pressure, or damage to oral health. Liver damage can be indicated if urine becomes dark, skin or the whites of the eyes become yellow, bowel movements become lighter in color, and the stomach or bowel area is consistently cramping or in pain. Lightheadedness or dizziness can indicate a change in blood pressure. Because even prescribed doses of Suboxone can cause dry mouth, Suboxone abuse may lead to a lack of saliva in the mouth, leading to a buildup of plaque and bacteria. This causes gingivitis and other periodontal diseases, which can lead to tooth decay and illness.
Overdosing on Suboxone
Per SAMHSA, in their 2010 Drug Abuse Warning Network (DAWN) Report, buprenorphine was increasingly found in people being admitted to the emergency room. In 2005, there were 3,161 ER admissions involving buprenorphine; by 2010, that number had increased to 30,1353. Of those, 52 percent were found to be nonmedical abuse of pharmaceutical drugs while 24 percent were people seeking help with detox for substance abuse and 13 percent were adverse reactions like an allergic reaction. Drugs in addition to buprenorphine were involved in 59 percent of the 2010 ER admissions, suggesting that the medication is becoming part of a larger pattern of polydrug abuse. The mixtures could also indicate people who were taking buprenorphine to self-treat opioid addiction or who took the medication as prescribed but relapsed into other drug abuse.
Of those ER admissions, 41 percent involved buprenorphine only, showing that it is possible to overdose on this drug. Signs of a Suboxone overdose include:
- Slow or irregular heartbeat
- Irritability, tension, or mood swings
- Loss of coordination and stumbling
- Sleepiness or falling unconscious
- Trouble concentrating
- Nausea, vomiting, or stomach pain
On the official website for Suboxone, a downloadable pamphlet of Important Safety Informationstates clearly that Suboxone can cause life-threatening breathing problems, overdose, and death; this is especially true when the filmstrips are tampered with and then taken intravenously, which is not appropriate use of this medicine, or taken with benzodiazepines, a class of drugs notorious for increasing the potency of opioids or alcohol. The pamphlet also warns not to consume alcohol while taking Suboxone.
People who have struggled with addiction to a stronger opioid like heroin or OxyContin are not likely to experience a high from Suboxone; however, people who have not developed a tolerance to other opioids will experience euphoria from Suboxone. For these people, overdosing on Suboxone is much easier – a little goes a long way.
Mixing Suboxone with other drugs, like methadone, benzodiazepines, or alcohol is also likely to enhance the effects of buprenorphine. Naloxone does not block alcohol or benzodiazepines, which may complicate overdose symptoms involving Suboxone and other drug combinations.
Withdrawing from the Withdrawal Medication
Because Suboxone contains a long-acting partial opioid agonist, the drug’s half-life is longer than shorter-acting, more intense opioid drugs like heroin. This makes withdrawal complicated for some people, so it is important to get a doctor’s help to ease off this medication with a taper.
Buprenorphine’s half-life is between 24 and 42 hours, so Suboxone withdrawal symptoms may not begin for the first day or two after a person stops taking the drug. This may induce a false sense of confidence, which could lead to more psychological suffering later. This is another reason it is important to work with a medical professional to safely detox from Suboxone; a doctor will give their patient important information about withdrawal symptoms beforehand.
Withdrawal from Suboxone can bring symptoms like:
- Runny nose
- Physical tremors
- Tingling or numbness, especially in the extremities
- Nausea and vomiting
- Abdominal cramps
- Appetite changes
- Rapid heart rate
- Cravings for Suboxone
- Obsession with acquiring more Suboxone
Like withdrawing from other opioid drugs, Suboxone withdrawal is not life-threatening, but it can be uncomfortable. It also lasts longer than other types of opioid withdrawal because of buprenorphine’s long half-life. Withdrawal can take at least two weeks but may become protracted withdrawal and last for a month or more.
Fortunately, working with a physician to oversee a safe detox process means that a tapering regimen can be managed to ensure withdrawal symptoms are not severe. For those who go off Suboxone completely and experience withdrawal symptoms, a doctor can also use over-the-counter drugs to ease pain, nausea, or feelings similar to the flu.
Treating Suboxone Addiction
Because Suboxone was intended to help people ease off other opioid addictions, there are established tapering schedules that doctors can use to help people lessen their dependence on this medication. It is not a good idea to stop taking the drug cold turkey, nor is it a good idea to attempt tapering without medical oversight. Detoxing with a doctor, then entering a rehabilitation program, is the best approach to treating Suboxone addiction.