Before discussing Suboxone, it is important to clarify a few terms.
The term medical detox is a term that is no longer commonly used by the majority of professional organizations that research and develop treatment protocols for substance use disorders. The reason for this is that the process of detoxification is naturally occurring.
Organizations, such as the World Health Organization and the American Association for Addiction Medicine (ASAM), have recognized that the term detoxification refers to a natural and ongoing process that the body uses to rid itself of foreign substances and impurities. Medical protocols did not substantially improve this process of detoxification, and individuals inevitably go through this process whether they experience withdrawal symptoms or not, whether they take addictive substances or not, and whether they are trying to stop using their substance of choice as a result of a substance use disorder or not. Thus, the term medical detoxification does not describe any useful intervention.
The process of withdrawal occurs as a result of the development of physical dependence on a substance. Physical dependence can occur in individuals who use certain types of drugs medicinally and do not have substance use disorders, as well as in individuals who abuse substances and develop substance use disorders. While physical dependence can be a symptom of a substance use disorder, its presence is neither necessary nor sufficient for the diagnosis of a substance use disorder in anyone.
What most people are referring to, and what the major organizations that study and develop treatment protocols for addiction (substance use disorders) mean, when they use the term medical detoxification is actually withdrawal management. Withdrawal management is a medically supervised process designed to assist individuals with physical dependence on some type of substance in negotiating the withdrawal process without experiencing significant symptoms (symptoms can be potentially fatal during withdrawal from some drugs). Withdrawal management programs typically involve the administration of medicines, specific tapering procedures, and other assistance to reduce the symptoms of withdrawal, such that the withdrawal syndrome is controlled and the individual is far less likely to relapse or experience detrimental effects.
What Is Suboxone?
Suboxone contains two medications buprenorphine and naloxone. The primary ingredient is buprenorphine, which is classified as a partial opioid agonist. The secondary medication in Suboxone is naloxone, which is classified as an opioid antagonist (meaning that it blocks the effects of opioid drugs).
Opioid drugs are drugs that are developed from the poppy plant and typically used medicinally to control the subjective experience of pain. Many of these drugs are highly abused and have a high potential for the development of physical dependence.
A number of common opioid drugs include heroin, morphine, Vicodin, OxyContin, codeine, etc.
Because prescription opioid drugs (also referred to as narcotic medications) are highly abused, and individuals who abuse them develop strong physical dependence on them, drugs like Suboxone were developed to assist in the withdrawal process from these drugs. Suboxone is considered to be an essential part of opioid replacement therapy to assist individuals in discontinuing narcotic drugs (see below).
According to The ASAM Principles of Addiction Medicine, the buprenorphine component of Suboxone is designed to bind to the same receptor sites in the brain that other opioid drugs bind to. This results in pain relief and mild euphoria, but not to the same degree that occurs with full opioid agonists like OxyContin or heroin. Taking buprenorphine fools the brain into thinking that the person is taking their drug of choice, and this reduces cravings and withdrawal symptoms.
In addition, buprenorphine is a longer-acting drug that occupies the receptor sites in the brain for nearly 24 hours, so if one takes any other narcotic drug or more buprenorphine, it will have no additional effects. These ceiling effects also prevent against the possibility that someone could overdose on Suboxone because after one takes a full complement of Suboxone, taking additional Suboxone does nothing.
The naloxone component of Suboxone is inert unless the individual tries to use Suboxone in a manner inconsistent with its designated use, such as grinding up and snorting it, injecting it, etc. It is activated in these instances. Naloxone is an opioid antagonist, which means that once it is activated, it immediately binds to the same receptor sites that opioid drugs bind to and knocks off any opioid drug already binding to the neuron receptor site, so the drugs cannot have any effects. It also triggers an immediate withdrawal reaction.
Thus, Suboxone was designed to be used in the treatment of physical dependence on narcotic medications/drugs. Typically, in a medical detox program that uses Suboxone, the physician will administer enough Suboxone to counteract any withdrawal effects and then over a period of weeks slowly taper down the dose of Suboxone so the individual’s system can adjust to decreasing amounts of the drug in their system. This way, the individual does not experience any severe withdrawal effects and can slowly be weaned off whatever opioid drug they are abusing or have developed physical dependence on.
Individuals who develop substance use disorders are often a resourceful group of individuals who may find a way to take a substance and turn it into a substance of abuse. Despite all the safeguards built into Suboxone, individuals do abuse this drug. For example, in 2010, there was a significant number of emergency room cases that were associated with the abuse of Suboxone that indicated a rising trend that Suboxone was being abused. There were over 30,000 emergency room cases due to Suboxone in 2010, and this represented an increase of over 3,100 such cases from 2005. Thus, even though buprenorphine is a partial opioid agonist that does not produce the full effects of opioid agonists like morphine, and even though Suboxone contains a built-in safety mechanism (naloxone), the drug has the potential for abuse. Individuals who abuse Suboxone will develop physical dependence on the drug and require withdrawal management in the initial phases of recovery.
Treatment for Suboxone Abuse
The treatment protocol for individuals who have opioid use disorders, including individuals who have developed a substance use disorder as a result of Suboxone abuse, is to:
- Start withdrawal management. Initiate a withdrawal management, or medical detox, program and taper the dose of Suboxone slowly, so the person can adjust and withdrawal symptoms can be minimized. Often, individuals may benefit from inpatient or residential treatment during the withdrawal management portion of the recovery process, as this allows for 24-hour monitoring and immediate attention for any complications.
- Institute a tapering strategy. Once the person can comfortably tolerate very small daily doses of Suboxone, the physician will totally discontinue the use of the drug, and the individual should be able to function without significant withdrawal symptoms.
- Engage in other treatment services. During the medical detox program, the individual should also attend substance use disorder treatment that includes medical management of any other issues, counseling for substance use disorders, family involvement, and participation in social support groups and other needed interventions.
- Get involved in aftercare. Once the individual is completely tapered off Suboxone, they should continue to participate in a long-term aftercare program that includes counseling, family involvement, social support group involvement (e.g., 12-Step group involvement), and other interventions, including continued medical treatment for any other psychological issues or other medical conditions.
Even though withdrawal from opioid drugs like Suboxone is not generally considered to be potentially dangerous (although it is quite uncomfortable), individuals should not attempt to withdraw from opioid drugs like Suboxone on their own. First, individuals attempting to withdraw on their own are extremely prone to relapse, whereas relapse rates for individuals in formal medical detox programs are significantly lower.
Secondly, according to sources like the American Psychiatric Association, many individuals who are diagnosed with substance use disorders also have co-occurring psychological disorders. Individuals in treatment for opioid use disorders will need to have any co-occurring psychological disorders treated concurrently in order for recovery to be successful.
Finally, individuals with certain types of psychological disorders, such as depression, anxiety disorders, personality disorders, etc., or who may not have formal disorders but may be susceptible to strong emotions and unpleasant physical feelings, who are undergoing withdrawal from opioid medications like Suboxone will also experience extreme emotional and physical discomfort that could result in them harming themselves either accidentally, due to poor judgment, or as a result of an intentional act (e.g., a suicide attempt). The risk is significantly reduced in a supervised withdrawal management program.
Individuals in withdrawal management programs can increase the benefits of their withdrawal management program and be proactive in their recovery by:
- Receiving education on withdrawal: By learning everything they can about substance use disorders, the withdrawal process, and strategies that encourage recovery, their likelihood of sustained recovery increases.
- Engaging in lifestyle changes: Adjusting one’s lifestyle, such as by eating nutritious foods; avoiding fat, sugar, and starchy foods; keeping a regular schedule; getting plenty of rest; and implementing an exercise program, can improve chances of recovery success. One need not be a fanatic about health; however, engaging in a healthy lifestyle will foster recovery.
- Developing positive social support: It is essential that an individual in recovery for any type of substance use disorder develop a strong social support network. This network should consist of family members and other individuals in recovery. Sometimes, it is necessary to cut ties with former associates who one used drugs with on a regular basis and to avoid places and situations where an individual commonly used drugs. For many individuals, social support groups, such as 12-Step groups, become part of the foundation of their recovery.
- Avoiding stress and boredom: Two of the biggest roadblocks to recovery are stress and boredom. Individuals who do not develop stress-management techniques during the recovery process are often vulnerable to relapse. It is important to ensure that an individual learns to manage stress without the use of drugs in order for their recovery to be successful. Boredom is often a trigger for relapse, and individuals should learn to develop goals, occupy their time, and understand that continually being idle may trigger relapse.
- Continuing to participate in recovery: Individuals in recovery often learn that recovery is a lifelong process, and that constant participation at some level in the recovery process is the best form of relapse prevention.