Suboxone

Suboxone maintenance treatment (SMT) is a comprehensive treatment program that involves the long-term prescribing of Suboxone for treatment of opioid dependence/addiction.

Buprenorphine has been available as a prescription opioid in Canada since 2008. It is marketed as Suboxone® in combination with naloxone in a sublingual tablet. It has been in the US since 2000.

Buprenorphine treatment provides an alternative to Suboxone maintenance treatment. Maintenance treatment with buprenorphine (or Suboxone), has been shown to be far more effective than detoxification in the treatment of dependence/addiction to opiods such as heroin, oxycontin, hydromorphone, fentanyl, morphine, etc.

This section is about the treatment program of “Suboxone maintenance treatment (SMT)“. For more information about Suboxone as a pharmaceutical agent, its other uses, side effects, and other properties, visit “About Suboxone”.

What is Suboxone Maintenance Treatment?

Suboxone is used as a long-term treatment for opioid addiction. Suboxone allows patients to lead normal, productive lives while working, caring for their families, and enjoying an active, healthy lifestyle. Suboxone treatment is voluntary, and the length of time a patient remains in treatment depends greatly upon the patient. Suboxone when taken orally under the tongue in an appropriate dose can suppress symptoms of opiate withdrawal while decreasing craving for opiates for 24 hours in most cases.

Isn’t Detox Better Than SMT?

Within the context of opioids, the definition of detox or detoxification is the management for relief of withdrawal symptoms such as aches, runny nose, chills, sweats, and insomnia, while the patient comes off opioids most often suddenly or “cold turkey”.  It is usually the first serious attempt at trying to control one’s uncontrollable substance abuse.  It is also one often urged by family and friends as in “drugs are bad for you; why don’t you just stop using?”  The problem with detox is that it ignores a key component of opioid abuse.  It assumes that a person is entangled in a vicious escalating cycle of substance abuse simply because of a cluster of flu-like symptoms that may last 5-10 days after stopping all opioid use.  Through detox, the person will get over the physical withdrawal symptoms, just as someone gets over a bout of flu.  However; the problem with the concept of detox emerges when one looks at the statistics that show detox has over a 90% failure rate.  Almost all the opioid-addicted individuals that finish detox (not even counting those that leave before the end), relapse to abusing their opioid of drug of choice after leaving detox.  The reason is that detox attempts to oversimplify a complex mental health diagnosis, i.e. addiction, into a basic physical ailment of physical dependence.  Very often, the opioid-dependent patient was using opioids for their euphoria, to deal with stress, or to self-treat a mental health disorder such as anxiety.  The individual’s brain cells thus became dependent on the external opioids just as much the rest of the body, in effect forgetting over time how to make their own natural opioids (i.e. endrophins).  Endorphins are essential in a person’s regulation of mood, thinking and emotional response.  So once the physical withdrawal symptoms have gone away after detox, the brain cells have not lost their dependence on the opioids for the person’s mood, energy and functioning level.  It is the mental withdrawal effects and the ensuing depression, anxiety, insomnia that soon cause the person to go back to using the opioids. This is why detox is almost always not successful in achieving rehabilitation.

In SMT, opioid-addicted patients are stabilized on an appropriate dose of methadone or Suboxone.  While on a stable dose, the patients then can go back to fixing the tolls that addiction took on their lives.  A stable dose in maintenance allows the patient to feel just normal, alert and functional without feeling any of the highs and lows that come with the abuse of the short-acting opioids such as oxycodone (OxyContin or Percocet), fentanyl, hydromorphone (Dilaudid), heroin, morphine, codeine, etc.  This stability also allows the patient’s brain to slowly adapt.  Once a patient has been stable in this way, and avoided all abused drugs, then an attempt could be possibly made in tapering the dose of Suboxone very slowly while carefully monitoring for signs of relapse.

Sometimes Subxone itself is used in a Suboxone-assisted detox program by starting and then reducing the dose over a short term, e.g 2-3 weeks. The same metioned issues that make non-assisted detox unsuccessful play at medication-assissted detox.

Who is SMT for?

If you’ve been abusing opioid drugs such as heroin, OxyContin, codeine, Dilaudid, Percocet and others, and you’ve come to a point where you know you can’t go on using, but you can’t seem to stop either, Suboxone maintenance treatment (SMT) may be right for you.  A physican consultation and examination is required to see who is a canadiate for SMT. SMT is generally useful for those who meet a diagnosis of opioid depedence based on the DSM IV (Diagnostic and Statistical Manual of Mental Disorders). The DSM IV criteria are based on a pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12‐month period (emphasis ours):

Tolerance, as defined by either of the following: A need for markedly increased amounts of the substance to achieve intoxication or desired effect or Markedly diminished effect with continued use of the same amount of the substance.

Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for the substance or The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms The substance is often taken in larger amounts or over a longer period than was intended.

There is a persistent desire or unsuccessful efforts to cut down or control substance use.

A great deal of time is spent on activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain‐smoking), or recover from its effects.

Important social, occupational, or recreational activities are given up or reduced because of substance use.

The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine‐induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).


Should I Go On Methadone or Suboxone?

If you’ve been abusing opioids, either MMT (methadone) or SMT (suboxone) may be right for you.  However, experience has shown that MMT is more effective than SMT within certain groups when it comes to helping patients get off and stay off abused opioids.  These groups comprise the following:

1. Have been using opioids for a long time, at high doses and have developed high tolerance to them.

2. Engage in high-risk/reward behaviours such as IV injection of drugs, inhaling smoked drugs, and mixing drugs.

3. Who are socially unstable, without a support structure, or stable housing.

4. Those who have failed suboxone treatment in the past.

These groups would benefit more from long-term treatment with methadone.  Furthermore, there are the issues of cost as suboxone is not routinely covered by the provincial drug prgorams, while methadone is.

How long is SMT?

This is a very common question. There is still no one answer to this question. What we can say is that most people who are successful coming off, without future relapse, show three important characteristics:

1. Their lives have been stabilized after they’ve been on Suboxone maintenance treatment for more than a year.

2. The decision to stop taking Suboxone iss made with their doctor, who gradually decreases the dose while providing support.

3. They’ve made changes in their lives that show they’re stable. For example, they may have a stable family life, support from the non-drug-using community, steady employment and fewer financial or legal difficulties.

It’s important to understand that Suboxone, when taken as prescribed, is a safe and effective medication that individuals can take for years. We encourage you to use it as long as you feel it’s working for you, and there are no medical concerns.

How Do I Get on SMT?

First you have to see our physician, who will do an assessment. If found to be suitable for the treatment, you could be started in the program the same or next day. You can call for an appointment here.

Suboxone has some special properties that make it unique in the treatment of opioid addiction.  For those starting or restarting SMT, the precipitated withdrawal syndrome is a real painful possiblity.  Therefore, patients are required to start treatment after 1 day of no other opioids taken and 3 days of no methadone taken.  If this advice is not followed, precipitated withdrawal is very likely.

What is the Goal of SMT?

Suboxone maintenance is a long-term treatment for addiction to opioids. Once a patient is stabilized on a stable dose of Suboxone, the negative thoughts, associated with addiction, often diminish and go away. The patient’s life tends to normalize and functioning increases, which can include caring for their families, working, achieving educational goals, addressing both mental and physical health co-occurring disorders and enjoying an active, healthy lifestyle. Achieving a healthier, normal life through Suboxone maintenance is a valid form of recovery from opioid addiction. Improvement in all areas of health and social integration increase with the length of time in treatment. The greatest positive change comes in the first year of treatment.

Similar to the medicines prescribed for diabetes, asthma, high blood pressure, depression, or other chronic medical problems, suboxone is not a magic treatment. No single medication or behavioral intervention can be a magic bullet for all patients seeking help for opioid addiction and the medical, psychiatric or social problems which may co-exist with it. The proper use of medication eliminates withdrawal symptoms and the craving for heroin, oxycodone, hydromorphone or other opioids and the structure and counseling required and offered provides an opportunity for patients to address problems and issues related to their addiction.

How Is Suboxone Taken?

A Your doctor will provide the pharmacy with a prescription for your Suboxone. This prescription must be renewed periodically by your doctor. He or she will determine how often you come for appointments, depending on your needs and progress. Suboxone is a medication that is taken sublingually.  It should not be swallowed as it does not have good absorption from the gut. When you first start on Suboxone, you will be asked to go to your pharmacy each day to take the medication. As you progress in your treatment, you may be eligible to take home some doses. These are called “carries.” Your carries must be stored safely to make sure the medication is not taken by anyone else, especially a child.

Is SMT a Cure?

It depends on how one defines cure. Suboxone in SMT is a medication that will control your addiction, so you can get back to normal functioning in life. If one defines cure as absolute abstinence from all opioids, there is no medication or technique that has been shown to achieve that. However if one defines cure as getting back to normal functioning, work and family life, then suboxone maintenance can be viewed as an effective cure .

How Do I Get Off SMT?

Unless ordered by a court, SMT is voluntary, so you can stop it at any time. However, studies have shown to successfully stop suboxone without a very high chance of relapse to abusing other opioids, one has to be in the program at least 1 year (preferably 2) from the last use of illicit hard drugs. A successful taper of methaone can be tried very gradually over a 3-6 month period, while carefully monitoring for signs of relapse to illicit drug use.

Do You Give Carries?

Take-home doses of Suboxone or “carries” are an essential part of an SMT.  Generally patients that have been on a stable dose, without missing doses at the pharmacy, who are medically/sociallly stable  without problematic drug use are gradually given carries.