Suboxone

Also known as

Subbies, temmies, bupe

Classification

Substitution treatment

Overview

Suboxone is one part Naloxone to every four parts Buprenorphine .. Suboxone contains a combination of buprenorphine and naloxone. Buprenorphine is an opioid medication, sometimes called a narcotic. Naloxone blocks the effects of opioid medication, including pain relief or feelings of well-being that can lead to opioid abuse .

Suboxone is used to treat narcotic (opiate) addiction.

Suboxone is not for use as a pain medication .

Medical usage

Used in substitution treatment for opioid drug dependence. When taken sublingually as prescribed, the Naloxone component of the treatment has no effect, due to its poor bio-availability through this route. However if injected, the naloxone component will be activated, causing withdrawal symptoms which makes the drug unattractive for misuse .

Source

Diverted from manufacturers, pharmacies, GP's prescriptions .

Street price

Ranging from £1 to £10 .

Why take it?

Sought after effects

• long-lasting,
• less drowsy than methadone,
• forces user into full withdrawal ,
• euphoria,
• reduced anxiety,
• relaxation ,
• feelings of euphoria,
• feelings of calm and well-being,
• reduced sensations of physical pain,
• reduced cravings for other opiates .

Undesired effects

• none of the pleasurable effects attributed to recreational opiate use,
• cannot use heroin or other opiates on top ,
• headache,
• nausea,
• insomnia,
• sweating .

Pharmacology

Buprenorphine has both opiate agonist and antagonist properties. Opiates latch onto receptors on nerve cells. In doing this they displace and over time replace the indigenous endorphins. Some opioids stimulate the receptors (agonists), some occupy and block action at the receptor site (antagonists), while a third group can do either, depending on what is happening at the receptor on contact. We call this third group partial agonists or agonist/antagonists and buprenorphine falls into this category.

Buprenorphine (Subutex) itself binds more strongly to receptors in the brain than do other opioids, making it more difficult for opioids to act at the relevant sites when buprenorphine is in the system. Interestingly, while methadone's effectiveness is generally thought to increase with dose (certainly up to 120mgs for maintenance, although most patients will not require this dose), buprenorphine has a ceiling effect at 32 mg, meaning that higher doses provide little or no extra benefit.

It is often considered that Suboxone/ Subutex is less stigmatised than methadone. It is probably fair to assume the drug formulations are identical, if taken as prescribed, that is not crushed for injecting, snorting or smoking. While the first day or two may be difficult, most patients are stabilised by the second day and these products are even longer acting than methadone, so may not require daily dosing and missing a day is less problematic. Side-effects, such as sweating, fatigue and constipation are often less marked than with methadone. Suboxone is however not for everyone and may not fully satisfy cravings or block withdrawal symptoms for those with very high tolerances.

Good guidance is published by The Royal College of General Practitioners on Buprenorphine and it seems both from this source and anecdotally that patients on higher doses of heroin can transfer straight from street heroin more effectively than might be supposed given the caution on dosing with methadone change overs. The delay before initiating should be at least 12 - 18 hours with heroin and 24 hours since the last dose of methadone, however if the person is clearly in withdrawal it should be assumed that starting buprenorphine will not exacerbate the condition and make matters worse. There will be considerable inter-person variation .

Mode of use

Orally or injection. Tablets may be crushed and injected .

Signs of usage

• random packages appearing at one's home or work,
• running out of the medication before the intended prescription schedule,
• unusual behaviour,
• strained relationships with loved ones ,
• withdrawing from family and friends,
• loss of interest in normal activities,
• difficulty maintaining responsibilities such as work and family,
• excessive sleepiness or difficulty sleeping,
• lying and manipulating,
• constantly thinking about obtaining and using the drug,
• stealing money or drugs,
• doctor shopping or frequent visits to the accident and emergency department .

Effects

Minor effects

More common

• abdominal or stomach pain,
• constipation,
• lack or loss of strength,
• nausea,
• pain,
• trouble sleeping,
• vomiting .

Less common

• back pain,
• diarrhoea,
• runny nose,
• sneezing,
• stuffy nose .

Major effects

More common

• cough or hoarseness,
• feeling faint, dizzy, or lightheaded,
• feeling of warmth or heat,
• facial flushing,
• fever or chills,
• headache,
• lower back or side pain,
• painful or difficult urination,
• sweating .

Incidence not known

• bloating or swelling of the face, arms, hands, lower legs, or feet,
• rapid weight gain,
• tingling of the hands or feet,
• unusual weight gain or loss .

Side-effects

• nausea,
• difficulty sleeping,
• attention problems,
• blurred vision,
• constipation,
• insomnia,
• hypotension,
• sweating,
• dizziness,
• fainting,
• respiratory depression .

Overdose

• blurred vision,
• breathing difficulties,
• confusion,
• cyanosis,
• dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position,
• drowsiness,
• irregular, fast, slow, or shallow breathing,
• pinpoint pupils,
• relaxed and calm feeling,
• sleepiness,
• unusual tiredness or weakness .
• profound drowsiness,
• intermittent loss of consciousness,
• lack of coordination,
• slurred speech,
• sluggish reflexes .

Withdrawal

Timeline

Here's an outline of the whole withdrawal timeline -

• 3 days after your last dose - This period is the worst, as the symptoms - especially the physical ones - will be at their peak,
• 1 week after your last dose - Body aches, mood swings, and insomnia will be the main causes of your discomfort by this point,
• 2 weeks after your last dose - After 2 weeks, most symptoms subside, but depression will persist,
• 1 month after your last dose - Drug cravings and bouts of depression can still occur even at this point .

The withdrawal symptoms usually include -

• nausea,
• vomiting,
• headaches,
• muscle aches,
• insomnia,
• lethargy,
• digestive distress,
• anxiety,
• depression,
• irritability,
• drug cravings,
• fever,
• chills,
• sweating,
• headache,
• concentration difficulties .

Drug testing

How long does suboxone stay in the urine?

Up to 3 days .

Harm reduction

Some of the advantages of Subutex can be seen as disadvantages, depending on the perspective adopted; it has little euphoric action and is a very effective antagonist if used in conjunction with heroin, therefore transitions from heroin to Subutex/Suboxone need to be handled carefully with at around 18 hours between the last heroin dose and first tablet. If this seems too long, it is safe to initiate when opiate withdrawal symptoms are observed. Using heroin on top of Subutex will not cause withdrawal; it will block the sought-after effects. It is important to note, that for reasons we do not fully understand, with some individuals the drug will act atypically. For example, while rare, some heroin dependent people seem to be able to use heroin 'on top' of sub-lingual Suboxone with no negative effects and little or no diminished euphoria. Be aware of the potential loss of partial tolerance to opiates effects on cessation of Subutex/Suboxone.

Subutex users should carry a card identifying themselves as patients on this substance in case of accident; it is necessary for doctors to know their status in order to correctly prescribe pain medications etc .

Paraphernalia

If tablets are injected - needles and syringes, water, matches or lighter, spoon .

Addiction treatment options

As with any opioid, suboxone abuse treatment follows a pattern dependent on the needs of the person in recovery .

Detox

The first stage is detox, where you'll be tapered off the drug until you are withdrawn from the substance altogether .

Addiction treatment

Once this stage is over, you'll be given counseling and therapy, which will explore the reasons for your addiction. You'll also be given psychological tools to combat the addiction, often in the form of cognitive behavioral therapy. This treatment can occur in a residential rehab or outpatient setting. Each setting has benefits based on the specific needs of the person in recovery.

Once outpatient treatment is established, many people will be referred to join peer support groups, such as a 12-step program, that will support you in your recovery. Active participation in a support group setting provides access to mentoring, fellowship, and shared experiences, and can be very helpful for people in various stages of recovery .

History

Reckitt & Colman (now Reckitt Benckiser), and McFarlin Smith, began trials with buprenorphine on human subjects in 1971, in 1978 buprenorphine was first launched in the UK as an injection to treat severe pain, with a sublingual formulation released in 1982. The drug was marketed intensively towards the end of the 1990's as Subutex, with its decreased respiratory action compared to full opiate agonists as its major selling point. Temgesic had already gained a relatively modest reputation as an opioid analgesic, but its progress was set-back by strong anecdotal experience of patients injecting the tablets, particularly in Scotland in the 1980's. The adoption of Subutex as a treatment of equal first choice (with methadone) by NICE for opiate dependence ensured its widespread use in addiction treatment .

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