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Suboxone

This content was written by: Justin Baksh, LMHC, MCAP, Chief Clinical Officer

suboxone-logo-rehab-treatment-center, suboxone, Foundations Wellness CenterSuboxone treatment gives individuals the opportunity to experience long-lasting, true recovery from addiction.

Offering a full range of care, suboxone treatment centers allow clients to get the root of their addiction, resolve trauma and learn new coping skills – all without the ill effects of withdrawal. Clients can focus on and participate in their treatment comfortably, as well as gradually build a new social network, find employment, and continue receiving support as long as they may need it.

Many people have questions about Suboxone treatment. Following are answers to the ones we hear most often from both those struggling with addiction as well as their loved ones.

What is Suboxone used for?

Suboxone is an FDA-approved prescription medication for the treatment of opioid use disorder. The American Society of Addiction Medicine recommends Suboxone treatment to reduce opioid withdrawal symptoms.

Suboxone is a combination of two medications, buprenorphine and naloxone.

  • Buprenorphine is a unique medication that acts as both an opioid partial agonist and an opioid antagonist. What does this mean? It activates opiate receptors in the brain, but only partially. This keeps withdrawal symptoms and cravings in check without causing the same level of “high” one would get from an opioid. Its antagonist properties block the effects of other opioids as well.
  • Naloxone is the generic name of the well-known drug Narcan.® As an opioid antagonist, naloxone counteracts the life-threatening effects of an opioid overdose. It reverses respiratory and nervous system depression and restores normal breathing. Because it blocks the effects of opioids, it will put the user into withdrawal immediately. When Suboxone is taken as prescribed, very little of the naloxone is absorbed, so it has no effect. However, if the Suboxone film or pill is injected instead of dissolved in the mouth, it stays active and causes an intense and sudden wave of withdrawal symptoms. By including naloxone in the formulation of Suboxone, manufacturers aim to prevent abuse of the medication.

As mentioned above, Suboxone comes in the form of a pill or film. Both are dissolved in the mouth, either sublingually (under the tongue) or buccally (between the gum and the cheek), once a day.

Suboxone film comes in four strengths, each with a 4-to-1 ratio of buprenorphine to naloxone:

    • 2 mg buprenorphine/0.5 naloxone
    • 4 mg buprenorphine/1 naloxone
    • 8 mg buprenorphine/2 mg naloxone
    • 12 mg buprenorphine/3 mg naloxone

The Suboxone sublingual tablet comes in two strengths:

    • 2 mg buprenorphine/0.5 naloxone
    • 8 mg buprenorphine/2 mg naloxone

Your clinical team, in coordination with your physician, will work together to find the right dose of Suboxone for you.

Does Suboxone work?

Suboxone has been shown effective at keeping people in treatment for 24 weeks. This is an ample amount of time to establish a firm foundation for a clean and sober life.

The reason Suboxone works so well is that one of the main reasons people leave treatment before completion is because of the withdrawal symptoms they are experiencing, both acute and post-acute.

Acute withdrawal symptoms typically last about a week; post-acute withdrawal syndrome can also last up to about six months.

Without these bothersome symptoms, clients can focus on treatment and rebuilding their lives without the distraction of feeling physically ill or mentally “off.”

Is Suboxone a controlled substance?

Yes, the FDA considers Suboxone to be a controlled substance.

Classifying drugs according to their potential for addiction and abuse, the Controlled Substance Act established a five-point system. Schedule I drugs have the highest potential for abuse and dependence and Schedule V, the least.

As a Schedule III drug, Suboxone falls in the middle of this scale. It carries a “moderate to low” potential for dependence development.

The Drug Addiction Treatment Act (DATA) also limits the prescription use of Suboxone. Healthcare providers who want to prescribe Suboxone must:

    • Meet qualifying requirements; including specialized training and certification by the federal government
    • Notify the Secretary of the HHS (Health and Human Services) of their intention to prescribe Suboxone for opioid dependence
    • Be assigned a unique identification number which is to be included in each prescription given

Initially, physicians were limited to treating 100 patients with suboxone. However, in 2016, that limit was raised to 275 patients – for those providers who met certain criteria. Specifically, providers must:

    • Be certified in addiction psychiatry or medicine by one of three addiction medicine boards (American Board of Addiction Medicine, American Board of Medical Specialties, or the American Society of Addition Medicine), and
    • Ensure they provide a qualified practice setting, certifying that they follow evidence-based guidelines for opioid use disorder treatment and provide behavioral health services, among other requirements.

Is Suboxone a narcotic? Is it an opiate or an opioid?

Suboxone fits the profile of a narcotic as well as an opiate or an opioid. There is an important difference, however.

Originating from the Greek word for “stupor,” narcotics referred drugs that relived pain by dulling the senses, according to the DEA:

“Though some people still refer to all drugs as ‘narcotics,’ today ‘narcotic’ refers to opium, opium derivatives, and their semi-synthetic substitutes. A more current term for these drugs, with less uncertainty regarding its meaning, is ‘opioid.’ Examples include the illicit drug heroin and pharmaceutical drugs like OxyContin, Vicodin, codeine, morphine, methadone, and fentanyl.”

Dictionary.com adds another element to the definition of a narcotic as not just a mood- and behavior-altering drug, but also one that is “sold for nonmedical purposes, especially an illegal one.”

Suboxone fits the first part of this definition but not the second. Suboxone is technically an opioid, but does not fully operate like one.

Yes, it alters mood and behavior by blocking opiate withdrawal symptoms. However, because naxolone is included in its makeup, it can cause immediate withdrawal symptoms. Therefore, it is next to impossible to abuse Suboxone.

When Suboxone is sought after on the street, it typically used to relieve withdrawal symptoms and not to get high.

Does Suboxone make you high?

Although Suboxone binds to the same receptors that opioids such as heroin, oxycodone and morphine do, it also blocks some of those receptors as well.

Therefore, any “high” you would feel from taking Suboxone would be very slight.

Can you overdose on Suboxone?

Yes, high doses of Suboxone can lead to overdose. Like other opioids, misuse and abuse can cause problems breathing, bring on a coma and even lead to death.

Misuse of Suboxone or combining it with other opioids, alcohol or benzodiazepines (Xanax, Valium, Ativan, et. al.) is more likely to cause these serious consequences.

Using cocaine with Suboxone also increases overdose risk. Because Suboxone is a depressant, it blunts cocaine’s stimulating effects. Users wrongly feel they can use more cocaine and can wind up overdosing.

Can you shoot, snort or smoke Suboxone?

The naxolone in Suboxone is not absorbed very well into your system when you take it sublingually or buccally. Instead, it is broken down and destroyed in your gastrointestinal tract.

However, when you try to shoot snort, or smoke it, naloxone remains active and can cause opioid withdrawal.

Again, this is intentional on the part of the manufacturer as it cuts down on the possibility of abuse.

Does Suboxone show up on a drug test?

Suboxone will not show up on a drug test as positive for opiates.

In the unlikely event that you are tested for buprenorphine, Suboxone will show up as positive for it.

The majority of employers only test for the most common street drugs, however. Those include opiates, amphetamines, cocaine, marijuana and phencyclidine (PCP).

So while it is technically possible to include buprenorphine in the lineup of substances tested for, it is not a common practice.

Still, if you have a prescription for Suboxone or buprenorphine, you will be able to justify its use to potential employers or others testing for the presence of drugs in your system.

Suboxone Box and Film, Suboxone Treatment, Foundations Wellness CenterWhat does Suboxone look like?

Suboxone film looks like a rectangular band-aid. It carries an imprint identifying it and its dosage:

            • N2 for 2 mg buprenorphine/.5 mg naloxone
            • N4 for 4 mg buprenorphine/1 mg naloxone
            • N8 for 8 mg buprenorphine/2 mg naloxone
          • N12 for 12 mg buprenorphine/3 mg naloxone

In pill form, Suboxone is orange shaped like an suboxone pill front and back, Suboxone, Foundations Wellness Centeroctagon. On one side, a sword-like symbol is imprinted, and, on the other, the dosage is indicated – either:

  • N2 for 2 mg buprenorphine/.5 naloxone
  • N8 for 8 mg buprenorphine/2 mg naloxone

How soon can I start taking Suboxone?

The timing of your first dose of Suboxone can be tricky.

Starting too soon can throw you into precipitated withdrawal, a state of intense (but short-lived) withdrawal symptoms that are more severe than what you would normally experience.

This is why the involvement of a physician is key.

Under the care of a trained healthcare professional, patients can be observed and scored on the Clinical Opiate Withdrawal Scale (COWS).

The COWS measures the severity of the following withdrawal symptoms:

    1. Resting Pulse Rate
    2. Sweating
    3. Restlessness
    4. Pupil Size
    5. Bone or Joint aches
    6. Runny nose or tearing
    7. Gastrointestinal Upset
    8. Tremor
    9. Yawning
    10. Anxiety or Irritability
    11. Gooseflesh Skin

The official Suboxone Dosing guide recommends waiting until there is moderate withdrawal (a score of at least 13 on COWS) and a minimum of six hours after the last dose.

It is also recommended that the first dose be dissolved under the tongue rather than between the gum and the cheek, which reduces the likelihood of withdrawal symptoms.

Also, Suboxone is typically given in a divided dose initially, as a safety precaution. Patients are observed for one or two hours to be sure there is no precipitated withdrawal before administering the second dose.

Patients continue to be assessed the second through seventh days as well, and the dose either increased or stabilized, depending on symptoms (or lack thereof).

This process is called induction. Once you reach the dose that is right for you, you’ll be stabilized on a maintenance program of that dose.

The goal of induction is to stop the onset of withdrawal – as much as and as quickly as possible.  On maintenance, the goal of Suboxone treatment is to ease cravings, prevent opioid withdrawal symptoms and block opioids from having any effect should there be a relapse.

Only those who have been using short-acting opioids (heroin, oxycodone, morphine and codeine) should begin treatment with Suboxone.

Those who have been using long-term opioids (methadone, extended release medications, etc.) are more likely to suffer withdrawal symptoms if given Suboxone. It is recommended in this case that buprenorphine is used for the induction stage. Afterward, these individuals can be switched to Suboxone film.

What are Suboxone side effects?

As with any drug, Suboxone does have a risk of side effects, ranging from mild and serious.

Serious side effects include:

  • Breathing Problems (Respiratory and Central Nervous System Depression), Coma & Death

You are urged to contact your healthcare provider immediately if you:

        • Experience slowed breathing
        • Feel dizzy, faint or confused

Many reports of coma and death involved either injection of Suboxone or use of benzodiazepines, alcohol, buprenorphine, other CNS depressants in addition to Suboxone.

However, this was not always the case. So, be aware of this potential complication and contact your healthcare provider immediately if you notice breathing trouble.

Suboxone should be used with caution in those with compromised respiratory function, including those with:

        • Chronic obstructive pulmonary disease (COPD)
        • Cor pulmonale
        • Decreased respiratory reserve
        • Hypoxia
        • Hypercapnia
        • Preexisting respiratory depression

Opioids can also cause sleep-related breathing disorders such as sleep-related hypoxemia and central sleep apnea.

  • Risk of Overdose in Children & Opioid Naïve Patients

Children accidentally exposed to buprenorphine can experience severe and possibly fatal respiratory depression. Store Suboxone out of the sight and reach of children. Any unused medication should be destroyed appropriately.

Deaths have been reported in “opioid-naïve” individuals who received a two-milligram dose of buprenorphine intended to be used as an analgesic. Suboxone is not to be used as an analgesic.

  • Risk of Abuse or Dependency

As with any opioid, Suboxone carries a risk of abuse or dependency. Your treatment program may slowly and carefully taper the use of Suboxone once treatment is complete to avoid long-term dependency.

  • Elevation of Cerebrospinal Fluid Pressure

As with other opioids, buprenorphine may elevate the pressure of the fluid surrounding the brain the spinal cord. Elevated cerebrospinal fluid pressure (CSF) pressure can cause severe headaches and even vision loss. It is important to treat elevated CSF pressure in order to prevent permanent vision loss.

Because of this, Suboxone should be used with caution in those who have a head injury or intracranial lesions. It should also be used with caution if there are any circumstances in which cerebrospinal fluid pressure is increased.

  • Elevation of Intracholedochal Pressure

Choledochal means “relating to, being, or occurring in the common bile duct,” according to the Merriam-Webster dictionary.

The liver produces bile that helps with the digestion and absorption of fat into the bloodstream. The bile is stored in the gallbladder until it is needed, when the common bile duct carries it from the gallbladder and liver duct intersection through the pancreas and into the small intestine’s duodenum.

As do certain other opioids, buprenorphine increases the pressure at which bile passes through this system.

If you have any biliary tract issues or problems, talk to your physician about whether Suboxone is right for you.

  • Liver Problems (Hepatitis, Hepatic Events)

In some patients taking buprenorphine, there were reported cases of cytolytic hepatitis (a disease that causes liver cell destruction) as well as hepatitis with jaundice.

The severity of liver problems ranged from a mild elevation in liver enzymes (transaminases) that cause no symptoms and eventually pass, to hepatic necrosis (death of liver cells), liver failure and death.

There have also been reports of hepatorenal syndrome (progressive liver failure) and hepatic encephalopathy (temporary worsening in brain function that occurs with advanced liver disease).

In many of the cases where these adverse events occurred there was either:

        • A pre-existing liver enzyme abnormality
        • Hepatitis B or C
        • Use of other drugs that are potentially hepatotoxic along with Suboxone
        • A continuation of drug injection after starting Suboxone

These factors may have contributed or caused the adverse outcomes. However, in some cases, there was insufficient data to determine the cause, and it is possible that buprenorphine was the culprit.

Therefore, you will need to be watchful for the following symptoms. If you notice any of the following, call your healthcare provider immediately:

        • The white of your eyes or your skin turning yellow (jaundice)
        • Dark-colored urine
        • Light-colored stools
        • Loss of appetite
        • Stomach pain or nausea

Suboxone prescribing instructions recommend a liver function test be performed prior to treatment as well as monitoring during treatment on a periodic basis. If a hepatic event is suspected during treatment, further evaluation is recommended.

  • Hypersensitivity/Allergic Reaction

If you are allergic to either buprenorphine or naloxone, you should not use Suboxone. Reported allergic reactions include bronchospasm (tightening of the muscles lining the airways) angioneurotic edema (swelling of the tissue under the skin), and anaphylactic shock.

Seek immediate care if you experience any of the following:

        • Rash
        • Hives
        • Itchiness
        • Wheezing
        • Facial swelling
        • Loss of blood pressure
        • Loss of consciousness
  • Opioid Withdrawal

Inform your healthcare provider if you experience the following:

        • Shaking
        • Sweating
        • Runny nose/watery eyes
        • Diarrhea and/or vomiting
        • Muscle aches
        • Feeling hotter or colder than normal

If you abruptly stop taking Suboxone or taper off of it too quickly, you could experience withdrawal symptoms. Also, if Suboxone is abused or if it is initiated too soon after your last opioid use, it can bring on precipitated withdrawal.

  • Decrease in your Blood Pressure (Orthostatic Hypotension)

This may make you feel dizzy when getting up from a sitting or lying down position. Let your physician know about any dizziness you experience.

  • Adrenal Insufficiency

Adrenal insufficiency is a condition affecting your adrenal glands that causes your body to not make enough of certain hormones such as cortisol and aldosterone.

Opioid use has been associated adrenal insufficiency. It occurs more often when opioids are taken for more than a month.

Adrenal insufficiency symptoms can include:

        • Nausea
        • Vomiting
        • Dizziness
        • Fatigue
        • Weakness
        • Anorexia
        • Low blood pressure

Talk with your physician about any symptoms you develop while taking Suboxone. If they suspect adrenal insufficiency, it can be tested and treated.

  • Serotonin Syndrome

Serotonin is a naturally occurring chemical that aids in brain and nerve cell function. However, when too much accumulates in the body as it does when opioids are used along with serotonergic drugs, it can be life-threatening.

Serotonergic drugs include SSRIs, SNRIs, TCAs, monoamine oxidase inhibitors (MAOIs), antidepressants, trazodone, nefazodone, mirtazapine. Use of these drugs with opioids has resulted in cases of serotonin syndrome.

Symptoms of serotonin syndrome range from mild to serious:

        • Goose bumps
        • Shivering
        • Headache
        • Confusion
        • Diarrhea
        • Sweating
        • Fever
        • Rapid or Irregular heart rate
        • High blood pressure
        • Agitation/restlessness
        • Muscle rigidity, twitching or muscle coordination loss
        • Seizures
        • Unconsciousness

Tell your healthcare practitioner about any symptoms you experience.

  • Androgen Deficiency

Androgen deficiency (lower levels of sex hormones such as testosterone). This can lead to a range of adverse symptoms, from fatigue and depression to shrinkage of sex organs. Chronic opioid use has been associated with androgen deficiency.

  • Effects in Acute Abdominal Conditions

Buprenorphine, just like other opioids, may make it harder to diagnose acute abdominal conditions.

  • Anaphylaxis

Anaphylaxis is a severe allergic reaction that can be life-threatening. Cases of anaphylaxis have been reported with exposure to ingredients that are contained in Suboxone film.

  • Neonatal Withdrawal Syndrome

Prolonged use of opioids while pregnant can cause neonatal opioid withdrawal syndrome (NOWS) in infants.

If you are pregnant or are planning on becoming pregnant, discuss this with your physician or healthcare provider prior to beginning Suboxone treatment.

  • Impaired Ability to Drive or Operate Machinery

Your ability to drive or operate machinery may be impaired while taking Suboxone. This is especially true during the induction phase where doses are being adjusted. Use caution until you are reasonably certain the Suboxone does not affect your ability to drive or operate machinery.

Other side effects of Suboxone and/or active ingredient that emerged in clinical trials and after it was on the market include:

    • Numbness of the mouth (Oral Hypoesthesia)
    • Burning sensation of the mouth, tongue or lips (Glossodynia)
    • Blistering and ulceration of the tongue
    • Swollen, Inflamed tongue (Glossitis)
    • Inflamed, Sore mouth (Stomatitis)
    • Oral lesions (Oral Mucosal Erythema)
    • Vomiting
    • Constipation
    • Feeling intoxicated (Intoxication)
    • Inability to pay attention (Attention Disturbance)
    • Irregular heartbeat (Palpitations)
    • Insomnia
    • Excessive sweating (Hyperhidrosis)
    • Blurred vision
    • Peripheral edema

One of the clinical trials for Suboxone was a four-week study comparing it with Subutex. Researchers found the side effects of the two drugs to be similar. Those occurring in at least five percent of patients taking Suboxone 16 mg buprenorphine/4 mg naxolone sublingual tablets were:

    • Headache – 36.4%
    • Withdrawal syndrome – 25.2%
    • Pain – 22.4%
    • Nausea – 15%
    • Insomnia – 14%
    • Sweating – 14%
    • Constipation – 12.1%
    • Abdomen pain – 11.2%
    • Decreased blood pressure (Vasodilation) – 9.3%
    • Vomiting – 7.5%
    • Weakness/lack of energy (Asthenia) – 6.5%
    • Chills – 7.5%
    • Infection – 5.6%
    • Inflammation of the nasal membrane (Rhinitis) – 4.7%
    • Back pain – 3.7%
    • Diarrhea – 3.7%

It should be noted that some of these incidences were lower than those experienced in the placebo group, such as back pain (3.7% in the Suboxone group, 11.2% in the placebo group), infection (5.6% versus 6.5%), diarrhea (3.7% versus 15%), insomnia (14% versus 15.9%) and rhinitis (4.7% versus 13.1%).

During induction, the most common side effect was restlessness. The following other side effects were observed during induction:

    • Anxiety
    • Goosebumps (Piloerection)
    • Stomach discomfort
    • Irritability
    • Headache
    • Rhinorrhea
    • Cold sweat
    • Joint pain (Arthralgia)
    • Increased tearing (Lacrimation)

Long-term side effects of Suboxone include potential problems with fertility in both males and females.

For more information, see the full prescribing information for Suboxone or speak with your healthcare professional.

Are there any health conditions that make it dangerous to take Suboxone?

Your physician will consider your medical history and other factors before prescribing Suboxone. In addition, you should be sure to let your healthcare provider know of any preexisting conditions you may have, especially:

    • Kidney problems
    • Liver problems
    • Trouble breathing/lung problems
    • Enlarged prostate
    • Brain problem or head injury
    • Trouble urinating
    • Curvature of the spine that impacts your breathing (Scoliosis)
    • Gallbladder conditions
    • Adrenal gland problems
    • Addison’s disease
    • Low thyroid hormone levels (Hypothyroidism)
    • History of alcoholism
    • Mental conditions, such as hallucinations
    • Are pregnant or planning to become pregnant
    • Are breastfeeding or planning to breastfeed

What other drugs should I not take with Suboxone?

Because Suboxone can interact with other medications, you should also tell your physician about all the medications you are taking. The following drugs have been shown to “significantly” interact with Suboxone:

    • Benzodiazepines & other central nervous system depressants (alcohol, non-benzodiazepine sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, and other opioids)
    • Inhibitors of CYP3A4 (Macrolide antibiotics (e.g., Erythromycin; Azole-antifungal agents (e.g., Ketoconazole); protease inhibitors (e.g., Ritonavir)
    • CYP3A4 inducers (Rifampin; Carbamazepine, Phenytoin)
    • Antiretrovirals: Non-nucleoside reverse transciptase inhibitors (NNRTIs) (Efavirenz; Nevirapine; Etravirine; Delavirdine)
    • Antiretrovirals: Protease inhibitors (PIs) (Atazanavir; Ritonavir)
    • Serotonergic drugs (Selective Serotonin Reuptake Inhibitors or SSRIs; Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs); Tricyclic Antidepressants (TCAs); Triptans; 5-HT3 Receptor Antagonists; Drugs that Affect the Serotonin Neurotransmitter System; such as mirtazapine, Trazodone; Tramadol; Certain Muscle Relaxants, such as Cyclobenzaprine, Metaxalone; Monoamine Oxidase or MAO inhibitors that are intended to treat psychiatric disorders and also others, such as Linezolid and intravenous Methylene Blue)
    • Monoamine Oxidase Inhibitors (MAOIs) (Phenelzine; Tranylcypromine; Linezolid)
    • Muscle relaxants
    • Diuretics

Your healthcare provider will make the final decision on whether Suboxone treatment is appropriate for you.

Suboxone Treatment in Port St. Lucie, Florida

Midway between Orlando and West Palm Beach, along the Treasure Coast of Florida, Foundations Wellness Center is an addiction treatment center offering Suboxone as a part of its MAT (medication assisted treatment) program.

Along with Suboxone, clients receive individual and group counseling with Master’s level clinicians, neuro-psych testing, biofeedback, neurofeedback, yoga, massage and chiropractic sessions, sports/gym, nutritional classes with a Registered Dietitian, offsite excursions and more.

By living in a nearby sober living home, clients develop the skills they need to one day live on their own. Fellow residents offer support while a live-in house manager provides supervision and accountability. After treatment, clients can opt to continue living in the sober home for as long as is needed to solidify their new, addiction-free lives.

Suboxone is a powerful tool that can help you get from where you are now to where you need to be. The time is now, don’t put it off another day.

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