Frequently Asked Questions
The following information reflects my medication assisted program policy for opioid addiction. This information will not apply to other programs. You should seek answers from the programs before you enroll.
- I am allergic to Suboxone. Do you prescribe Subutex?
- What is the starting dose of Suboxone at your clinic?
- What is the duration of your Suboxone program?
- What is the success rate of your Suboxone program?
- Can one overdose on Suboxone?
I am allergic to Suboxone. Do you prescribe Subutex?
Suboxone contains Buprenorphine and Naloxone in combination. Subutex (Buprenorphine alone) is no longer manufactured or marketed by that name, but is now available as a generic preparation.
FDA has approved Buprenorphine + Naloxone formulation for outpatient treatment of opioid addiction. The Buprenorphine mono preparation is to be prescribed only under certain restricted conditions.
This is a deliberate decision by FDA to discourage misuse of Suboxone by injection. It balances the benefit of making Suboxone available by prescription, for use in the comfort and privacy of your home, as opposed to having to go to a Methadone clinic to get a daily dose.
Buprenorphine (commonly referred to as Subutex) is only recommended for:
- induction, that is, the first few days of treatment,
- for use during pregnancy,
- for patients who are allergic to Naloxone.
I prescribe Buprenorphine for induction, for a maximum of three days, followed by Suboxone, Bunavail, or Zubsolv. I do not treat patients who are pregnant, or are allergic to Naloxone.
Pregnant patients that are addicted to opioids and or other substances should discuss this with their obstetrician and seek referral to a high-risk pregnancy unit.
Specialized addiction treatment centers or addiction specialists are more likely to accept patients with allergy to Naloxone. Buprenorphine mono preparation may be available at the opioid treatment program where it is dispensed to patients on a daily basis, but not prescribed.
Patients with any evidence of IV drug use are almost never prescribed Buprenorphine mono preparation (Subutex).
True allergy to Naloxone is very rare. Naloxone (injection and nasal spray) is the only drug available to reverse the effect of opioids, and is used for treating overdose.
If it is on your record that you are allergic to Naloxone, then the emergency responder may not administer Naloxone to you when you OD … that seriously reduces your chance of survival.
So think about it before you go about making false claims about being allergic to Naloxone. Most patients who claim being allergic to Suboxone are describing the precipitated withdrawal that they experienced when they took Suboxone without waiting through the opioid free period of 12 to 72 hours.
Most office based providers will not prescribe Subutex. If you have a sound medical reason to take only Subutex then you might like to try specialized addiction treatment facilities and University Medical Centers.
What is the starting dose of Suboxone at your clinic?
That depends on whether the patient is receiving Suboxone for the first time, is restarting Suboxone after relapse, or is transferring from another practice.
- Patients starting Suboxone for the first time are prescribed 16mg/day for the first month, then 12mg/day for the following month.
- Patients transferring from another practice or restarting Suboxone after a relapse are started at 12mg/day or the dose that they were on before transfer, … whichever is lower.
Equivalent doses of Buprenorphine + Naloxone preparations:
Suboxone 8mg = Zubsolv 5.7mg = Bunavail 4.2mg
Patients who have never been prescribed Suboxone, have to go through in-office induction with Buprenorphine. The first dose of 4mg to 8mg has to be taken in the clinic. They are prescribed Buprenorphine 16mg for three days with instructions to take the lowest dose that prevents significant withdrawal.
They also receive a prescription of Suboxone (or a comparable medication in an equivalent dose), 16mg/day, for 30 days, with instruction to taper their dose as tolerated.
After 30 days, patients receive a maximum of 12mg/day. After one year patients receive a maximum of 8mg/day.
Majority of patients who are serious about recovery should be able to completely taper their Suboxone dose within one year … tapering over one year makes it a very gentle method, … without disrupting normal work or school routine.
Patients who need it for longer period … are not denied the medication, provided they have tapered their dose to 8mg/day or less, and have other social and professional indicators that justify ongoing medication assisted treatment.
What if 16mg (two films/day) is not enough for me?
For a majority of patients 8mg/day is enough to prevent significant withdrawal. One must go through mild withdrawal to force the brain to adapt to a lower opioid dose. However, I do prescribe 16mg/day as an allowance that some people may need to start at 16mg/day.
If 16mg/day is not enough for you, then you need to find a program that prescribes more.
As I have gained more experience treating addiction, I have found that 24 to 32 mg/day (that was strongly recommended by the manufacturer) is excessive.
In-patient facilities that prescribe and taper dose based on direct observation of withdrawal report that patients almost never need a dose exceeding 16mg/day … most need considerably less. Inpatient facilities rapidly taper the dose down to 2 to 4mg within a few days … to prepare patient for discharge.
There is extensive data from other countries that have state funded health plans for their citizens, … most of their patients receive 8mg/day … even hard core IV drug users, and do quite well.
Even if 8mg/day may not prevent all the symptoms of withdrawal … it is still enough to prevent major withdrawal … and it is still enough to allow patients to function well.
I have an outpatient clinic. I neither have the resources to follow the recommended protocol of seeing patients every few days to adjust their dose, … nor are patients willing to take time off to be seen every week, … nor are they willing to pay to be seen every week.
I accept only those patients that are appropriate to be enrolled in an outpatient program and can be followed-up once a month. It allows patients to work or attend school without disruption. My approach works for 90% of patients … the other 10% can go to a more intensive program.
What is the duration of your Suboxone program?
Duration is dictated by patient’s progress. I do not have a minimum or maximum duration.
Duration of treatment generally co-relates to the brain injury and alteration of adaptive behavior. For some willpower is not enough … and some do not have the will. There is no reason to dismiss long term treatment as inappropriate … it is far better than the alternative of repeated relapses and continued addiction.
Factors determining duration of treatment are:
- How long the person has used, … longer the use … longer the treatment.
- Quantity being used, … higher the quantity the longer the treatment.
- Other factors … for example poly substance use, multiple relapses.
- Comorbid disorders … coexisting chronic pain, psychological problems, etc.
Patients who want to taper their dose completely within one month, or three months, or six months, … can do so and are encouraged to do so. Some patients are over ambitious they think they can do it … they make good progress initially but are unable to taper off at lower doses. It is very easy to get down to 4mg/day or even 2mg/day … but beyond that it does become difficult.
There are several people in my program who have been on 2 to 4mg a day for a few years. A few have been on 8mg/day for two to three years. For the long term I do not keep any patient who needs more than 8mg/day. They are advised to seek help from some one more qualified.
On the other hand there are patients who are resistant to taper their dose. I expect most patients to come down to 8mg within three to six months. Beyond six months I do not wish to prescribe more than 8mg/day.
Patients are not discharged because they can not taper their dose … as long as they show that the treatment is beneficial to them. Patients are discharged mostly because of administrative issues, … not bringing blood test results, not keeping appointments, persistent refusal to follow recommendations, etc.
You do not get what you want … you get what you need. And you can get it as long as you need it.
What is the success rate of your program?
The success rate of my program is about 20%.
80% of the patients drop out.
For the remaining 20% … their success rate is 100%.
Can one overdose on Suboxone?
Suboxone is also an opioid, with similar side effects as other opioids, including the risk of overdose and death. That is why it is very important that the medication be secured, that only the patient have access to the medication, and that every tablet or film be accounted for.
In terms of Morphine Milligram Equivalent (MME), Buprenorphine is 10 times stronger than Morphine. In one CMS publication Buprenorphine is claimed to be 30 times stronger than morphine.
If used as prescribed Suboxone does not pose any danger. The risk of overdose death increases if one takes more than prescribed, or one takes it with other sedative drugs like benadryl, xanax, and alcohol.
Does the Naloxone in Suboxone prevent overdose?
Large quantity of Suboxone whether taken under the tongue, swallowed, or injected can cause respiratory depression and death.
The Naloxone in Suboxone is there to discourage intravenous use. When injected, the Naloxone prevents the immediate high that drug users are seeking through intravenous administration of opioids. Naloxone is a short acting drug and Buprenorphine is a long acting drug. The short acting Naloxone will block opioid receptors only for a short time while Buprenorphine will act for a very long time. Large quantity of Suboxone injected will eventually cause overdose and death.
When Suboxone is taken under the tongue or swallowed, only negligible amount of Naloxone is absorbed into the circulation, it is not enough to block the effect of Buprenorphine.
A toddler is specially vulnerable to overdose because the medication is rapidly absorbed once placed in the mouth. Toddlers generally spit out the medication but enough of it may be absorbed in that short period as to cause respiratory depression. Other people who are currently not using any opioids and are not tolerant to the effects of opioid are also at the risk of overdose.