Suboxone® Program

Buprenorphine Maintenance Treatment (BMT) is used as a long-term treatment plan for opioid addiction. If you are addicted to drugs like Heroin, Morphine, Oxycodone or Fentanyl, BMT could be the right treatment for you. Suboxone® contains buprenorphine and naloxone. Suboxone® is often prescribed by doctors because it is safer, has fewer side effects, and takes less time to reach the correct dosage. It allows you to lead a normal, productive life while on the road to recovery. 

Once you start taking Suboxone®, the dosage can be quickly and safely increased to help you get the right dose. Once the correct dosage is reached, Suboxone® can prevent withdrawal symptoms and craving for opioids like heroin, oxycodone, and hydromorphone. BMT patients often find that all negative thoughts related to addiction usually disappear. The main purpose of Suboxone® is to help you achieve a healthier, more balanced life. Most patients see a vast improvement during the first year of treatment. Suboxone® is no cure-all but works best with supportive services like counselling, which allows you to address problems related to your addiction.

The buprenorphine compounds that Road to Recovery patients take include Suboxone®, and Sublocade®. Suboxone® comes as small sublingual (under the tongue) tablets that are ineffective when swallowed. Sublocade® is a once-a-month intramuscular injection that is suitable for some patients already on the sublingual Suboxone®. All these medications contain a combination of buprenorphine and naloxone. Naloxone serves two purposes — blocking other opioids and deterring misuse. By causing withdrawal symptoms when taken incorrectly, naloxone reduces the risk of diversion. Road to Recovery medical providers help patients determine the best choice for their treatment. When you start using Suboxone®, you will have to make a daily visit to your local pharmacy to continue your treatment. Your doctor will provide the pharmacy with a prescription and will also determine how often you’ll need a consultation. As you progress, you may be able to take some doses home. These are called “carries.” 

The biggest limitation of Suboxone® is the need for patients to not use opioids for a period of time before starting the BMT therapy. This can be difficult for those with an opioid use disorder. Micro-dosing allows for the use of other opioids (either prescribed or illicit) until a stabilizing dose of Suboxone® has been achieved.

Your doctor will prescribe small doses of Suboxone® and slowly increase the dose and frequency. This process takes 7 – 10 days, and patients find this method of treatment manageable. Patients have consistently reported that the micro-dosing process is well tolerated, with a reduction or elimination of cravings and avoidance of withdrawal. 

Sublocade® in combination with counseling and psychosocial support, is a once-monthly medication-assisted treatment that contains buprenorphine, a mu-opioid receptor agonist. It uses the ATRIGEL® Delivery System and solidifies on contact with bodily fluids to deliver buprenorphine over the one month period. It is injected as an intramuscular preparation.

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Suboxone® is composed of both buprenorphine and naloxone. The naloxone is an antagonist for opioids. It causes withdrawal symptoms when injected or snorted. Naloxone does not work when the tablets are taken sublingually or orally. Buprenorphine, the opioid in Suboxone, was developed in the 1970s as a safer opioid than morphine or heroin for the treatment of pain. Studies suggested that buprenorphine could be an attractive alternative to methadone, as it could require fewer regulations because of its inherent abuse deterrence properties as a partial opioid agonist-antagonist. It has no effect on buprenorphine and does not cause withdrawal or other symptoms when other opioids are taken concurrently. Pharmacologically, buprenorphine has the benefit of providing only partial mu (μ) opioid receptor agonism along with high receptor affinity relative to other opioids.

Any patient over the age of 18 years, with a DSM-V diagnosis of opioid use disorder, can start Suboxone® treatment.

In general, patients cannot start Suboxone® if they have allergies to buprenorphine or naloxone, significant breathing issues (eg COPD), significant liver or kidney disease, or untreated alcohol use disorder.  The treating physician will review the medications a particular patient is taking in detail to identify any contraindications.

If you are not content with your initial decision you can switch between methadone and Suboxone® quite easily. Using the Suboxone® micro-dosing protocol you may slowly reduce the prescribed methadone dose while simultaneously increasing Suboxone® in micro-dose amounts over the span of 7-10 days. Similarly, you may transfer to methadone from Suboxone® with the help and support of a medical practitioner. 

As a full agonist, methadone has more than 4 times the risk of overdose than buprenorphine. Since Suboxone® is relatively safe when used appropriately, it is not uncommon for patients to receive most, if not all, carries early in their treatment program. This is different from methadone, where it takes many months to achieve full carries. This is advantageous for the Suboxone® patient, particularly if they attend school or are employed and do not have time to attend the pharmacy to observe their dose.

• On Suboxone®, you can reach the correct dose in 1-3 days, on methadone it may take weeks.
• There are fewer withdrawal symptoms when tapering down Suboxone®.
• Suboxone® has fewer side effects.

Methadone is a full opioid agonist, meaning it fully binds to opioid µ-receptors in the brain, blocking cravings and eliminating withdrawal symptoms. It produces opioid effects like sedation, euphoria, or respiratory depression until the receptors are fully activated or the maximum effect is reached. It’s generally taken once a day and comes in liquid forms.

One concern with methadone is the danger of ongoing opiate use during treatment.  If you take other opiates with methadone, the effects of both medications are enhanced. This can lead to a deadly decrease in central nervous system activity.

Suboxone® is a partial opioid µ-receptor agonist that contains both buprenorphine and naloxone. Similar to methadone, buprenorphine prevents debilitating withdrawal symptoms and cravings, but it also deters abuse by blocking the euphoric effects of other opiates. That means, if you take an opiate like OxyContin with buprenorphine, the buprenorphine essentially blocks its effects. The naloxone in Suboxone® serves as an additional abuse deterrent, causing acute withdrawal if injected.

Knowing you’re unable to abuse other opiates can be a blessing in early treatment. Instead of worrying about withdrawal or constantly feeding an addiction, you’re able to focus on your recovery with a clear mind.

Buprenorphine-naloxone comes in film and tablet forms that are placed under the tongue to dissolve. And a new once-a-month injection of buprenorphine, Sublocade®, is also available.  This is an excellent choice for patients that work in remote areas where a pharmacy is not readily accessible.  

Suboxone® is available in many formulations. The most popular are sublingual tablets, buccal film, and injectable Sublocade®. Many different protocols exist when initiating a patient on Suboxone®. The best protocol is individualized to the patient’s current situation.

In past years, it was required that patients needed to be in moderate withdrawal before starting Suboxone®, but recent studies suggest otherwise. In lieu of moderate withdrawal, patients can initiate Suboxone® using buprenorphine micro-dosing. This allows for small increments in the Suboxone® dose day-by-day over the span of about a week. This process slowly displaces illicit opioids from the (μ) opioid receptors and the patient forgoes the need to be in moderate opioid withdrawal.

The risk of precipitated withdrawal is also reduced with this protocol. However, if the patient presents in moderate withdrawal, the traditional protocol of 2 mg sublingually followed by a reassessment and probable increase in dose 45 minutes later.

There is no straight-forward answer, but most people who are successful in tapering off, without relapse, show the following:

• BMT was done for more than a year.
• The process was supported by a doctor who gradually lowered the dose.
• Positive lifestyle changes were made, for example, having a sound support system and stable employment.

As a partial agonist, buprenorphine theoretically has a smaller effect with a ceiling, a low overdose risk, and no intoxication in the opioid dependent population. As a full agonist, methadone has more than 4 times the risk of overdose than buprenorphine.

Suboxone® may cause serious and life‐threatening breathing problems. Get emergency help right away if you:

• feel faint
• feel dizzy
• are confused
• feel sleepy or uncoordinated
• have blurred vision
• have slurred speech
• are breathing slower than normal
• cannot think well or clearly

Do not take certain medicines during treatment with Suboxone®. Taking other opioid medicines, benzodiazepines, alcohol, or other central nervous system depressants (including street drugs) while on Suboxone® can cause severe drowsiness, decreased awareness, breathing problems, coma, and death.

• In an emergency, have family members tell emergency department staff that you are physically dependent on an opioid and are being treated with Suboxone®.
• You may have detectable levels of Suboxone® in your body for a long period after stopping treatment with Suboxone®.
  Death has been reported in those who are not opioid dependent who received buprenorphine sublingually.

In Ontario, call 911 in an emergency

Precipitated withdrawal is a sudden, rapid onset of withdrawal symptoms that can last for hours or even days, depending on the severity of the individual’s opioid use disorder (OUD). This condition is more intense than regular acute withdrawal from opioids. Precipitated withdrawal is most common in people taking buprenorphine. This may happen if they begin opioid addiction treatment before other opioids have left their body, or if they attempt to overcome their opioid use disorder without medical supervision. 

Symptoms associated with precipitated withdrawal are like those of acute opioid withdrawal, but they typically occur faster and feel more intense.  The likelihood of precipitated withdrawal is unlikely give checks and balances in a certified addiction clinic, including the use of the COWS (Clinical Opioid Withdrawal Scale) to measure the presence of moderate withdrawal prior to starting Suboxone® treatment.  More recently, the process of micro-dosing of Suboxone® has allowed for the initiation treatment in the absence of moderate withdrawal symptoms.

Suboxone® is not an opioid antagonist, but a partial opioid µ-receptor agonist.  In other words, it is a “stronger magnet” than many other opioids, including heroin, oxycodone, or hydrocodone. This means the buprenorphine binds more readily to µ-opioid receptors in the brain than most full opioid agonists, thus replacing them. Since buprenorphine does not trigger strong intoxication, especially in people who have an opioid tolerance, a sudden replacement of these opioids can cause withdrawal symptoms.  Therefore, the Suboxone® is given in a micro-dose following a stepwise fashion to prevent precipitated withdrawal.

Clinic visits with the doctor are fully paid for if you have a valid OHIP card.

In general, costs of medications may be covered under government plans such as Ontario Drug Benefits (ODB) or Non-Insured Health Benefits (NHIB), a private medical plan, or Trillium Drug Plan (TDP). Your pharmacist may try to assist you if you are having difficulty with payment.

Set up an intake appointment by contacting us by telephone or on-line as shown below. You can also drop by a RTR clinic and present your OHIP card. An initial appointment will be scheduled as soon as possible.

To become a patient you must:

• Be 18 years of age or older
• Have valid photo identification,including a valid OHIP number
• Opioid use disorder evidence must be present as per DSM-V criteria
• Agree to follow program policies & procedures
• Give full consent prior to starting medication assisted treatment (to be agreed upon and signed by the patient)
• A urine sample will be obtained periodically to assess for recent drug use