FAQ: What is the difference between Suboxone, Zubsolv, Bunavail, and Subutex, and is one superior to others?
All four products have similar action and are equal in equivalent doses. One is not superior to others. They do have some differences in how they are used, and how they taste. They also have different rebate programs, and one might turn out to be cheaper than others. However, the rebate programs and coupons keep changing, so self-pay patients need to check frequently. Patients who have insurance, … for them the prescription plan will have only one or two of these as the preferred product.
All four products
- have Buprenorphine as their main ingredient, and in equivalent doses have equal effect,
- are only approved for the treatment of opioid use disorder (formerly known as opioid dependence and opioid addiction),
- and require that the provider obtain a special certification from the Drug Enforcement Agency (DEA) to prescribe these medications.
Suboxone, Zubsolv, and Bunavail contain a combination of Buprenorphine and Naloxone.
Subutex is Buprenorphine without Naloxone.
Subutex (Buprenorphine Tablet)
Subutex (Buprenorphine) as a brand is no longer manufactured, and the name is now understood to represent the Buprenorphine mono preparation.
Subutex used to be marketed as a 2mg and an 8mg tablet. After the patent expired the manufacturer stopped making and marketing it under that brand name. The generic form of this medication is easily available and is cheaper than generic Suboxone. The name has become popular, is easier to pronounce than “Buprenorphine”, and is still being used.
If the provider writes a prescription for Subutex, then the pharmacist will dispense Buprenorphine (without Naloxone), made by one of the generic manufacturers.
Subutex (Buprenorphine) is the only product out of the above four that does not have any Naloxone.
The current recommendations restrict its prescription to specific situations.
Subutex is recommended to be used for:
- induction, that is starting someone on Buprenorphine for the first time (prescribed for the first few days),
- patients who are pregnant, (even though Buprenorphine is not yet recommended for use in pregnancy),
- patients who are allergic to Naloxone.
Subutex does not contain Naloxone … therefore it has abuse potential, and diversion potential. Patients or others who may acquire it through illicit means, may crush these tablets and inject it … after all Buprenorphine is an opioid agonist, and produces opioid like effects. Given this potential for misuse, most providers in USA will not ordinarily prescribe Subutex.
The other three formulations, Suboxone, Zubsolv, and Bunavail, have Naloxone, … so that if injected the Naloxone component will block the immediate effects of Buprenorphine … thus removing the incentive for an intravenous user to inject it.
The Naloxone component in these three preparations is quite significant. When Naloxone is used for reversal of opioid overdose the ER physician will typically give 0.2 mg intravenously, in incremental dose, till reversal is achieved and sustained. On the average it takes anywhere from 0.4mg to 1.2mg of IV Naloxone, that is one to three ampoules of Naloxone (each ampoule being 0.4mg of Naloxone).
Compare that to Naloxone nasal spray (Narcan), … which has 2mg and 4mg per dose. This is ten times the dose that is available as an injection, because the nasal absorption of Naloxone is not that good … ten times the injectible dose is needed to get any appreciable effect.
The combination products Suboxone, Zubsolv, and Bunavail, in their most common prescribed form, have 0.7 to 2mg of Naloxone, enough to block any immediate euphoric effect of Buprenorphine, if injected intravenously.
However, if they are taken as prescribed, then only a negligible amount of Naloxone gets absorbed … and does not have any significant blocking effect
Suboxone, Zubsolv, and Bunavail, have similar cost for equivalent doses. Prescription plans will generally have only one of them as their preferred drug in their formulary.
The different forms of medications have differing amounts of Buprenorphine and Naloxone. Mnufacturers claim that their product has better absorption and bio-availability so their lower dose delivers an equivalent amount of Buprenoprhine.
The most common forms of these medications that are available have the following amount of Buprenorphine and are considered equivalent dose.
Generic Buprenorphine 8mg/Naloxone 2mg available as a sublingual tablet.
Suboxone Buprenorphine 8mg/Naloxone 2mg available as a sublingual film.
Zubsolv Buprnorphine 5.7mg/Naloxone 1.4mg available as a sublingual tablet.
Bunavail Buprenorphine 4.2mg/0.7mg available as buccal film.
Buprenorphine + Naloxone Generic Tablet
Sometimes referred to as Suboxone generic tablet because it replaces the orange colored Suboxone tablet that used to be available till a few years back. It contains Buprenorphine and Naloxone in combination, it is now marketed as a white tablet and may come in different sizes and shapes as there are multiple generic manufacturers.
This generic tablet is available in two strengths:
- Buprenorphine 2 mg/Naloxone 0.5 mg, tablet
- Buprenorphine 8 mg/Naloxone 2 mg, tablet
The commonest strength prescribed is Buprenorphine 8mg/Naloxone 2mg tablet that is placed under the tongue from where the medication is absorbed. The tablet can be cut into half with a tablet cutter, but cutting it any smaller than that is difficult. Some pharmacies have tiny tablets, easy to use but impossible to cut. That makes tapering on an existing prescription difficult, … the pieces crumble.
This also comes as a Buprenorphine 2 mg/Naloxone 0.5 mg tablet, but is difficult to find and the cost is not exactly one fourth of the 8mg tablet, making it a poor value. Patients who have tapered their dose to 2mg/day may find it useful.
This is generally the least expensive form of Buprenorphine + Naloxone without any coupons. This also happens to be on more formularies than branded products. Other brands tend to compete and offer coupons or other rebates that reduce the price difference for a self-pay patient.
Patients do not have to purchase the entire prescription, they can purchase a few tablets at a time, however, discuss this with the pharmacist, as each pharmacy has its own rules.
The retail cost per 8mg tablet is anywhere between $4 to $8. Being a generic formulation there are no rebate cards. It is best to compare retail prices and download coupons for your zip code through services like:
When comparing prices make a note of how many tablets, and what strength. I find that sometimes they are giving the cost of 14 tablets and sometimes 30.
Suboxone Film (Buprenorphine + Naloxone)
Suboxone contains Buprenorphine and Naloxone in combination, marketed as a film in a sealed foil pouch. Each pouch has one film. 30 patches to each pack. The commonest strength prescribed is Buprenorphine 8mg/Naloxone 2mg.
Patients do not have to purchase the entire prescription, they can purchase a few films at a time, however, for cash purchases buying the entire pack of 30 gets the maximum savings.
The retail cost per 8mg film is anywhere between $6 to $12. It is on the formulary of some prescription plans, but might require preauthorization.
With my patients Suboxone film remains popular because, it is easy to carry, and the film can be cut to very small pieces … which makes it useful when a patient is tapering the dose.
Once the patent for Suboxone tablet expired the manufacturer introduced the current Suboxone film and claims that it is safer because little children can not take it, thus preventing accidental ingestion. They claim that it is safer because it is not a tablet, it is not attractive, each film is sealed in a pouch that requires scissors to cut it, etc.
Suboxone film is available in four strengths:
- Suboxone Buprenorphine 2 mg/Naloxone 0.5 mg, film
- Suboxone Buprenorphine 4 mg/Naloxone 1 mg, film
- Suboxone Buprenorphine 8 mg/Naloxone 2 mg, film
- Suboxone Buprenorphine 12 mg/Naloxone 3 mg, film
Suboxone 8mg film (Buprenorphine 8mg/Naloxone 2mg) is the most popular form with my patients that are tapering their dose. The 2mg film has one fourth the medication but costs almost as much as the 8mg film, so it is very poor value. Some patients have problems getting dosage forms other than the 8mg film, … as those prescriptions get rejected by their prescription plans, and the pharmacy does not ordinarily stock them.
The manufacturer offers a rebate for both self-pay and insured patients. You can download rebate card from Suboxone website:
The patent on the suboxone film is set to expire in 2024. In August 2017, The District Court of Delaware has ruled in favor of Dr. Reddy’s Laboratories against Reckitt Benckiser, for their version of the Suboxone film. It is still working its way through the courts, and until other manufacturers bring their product to the market the price of Suboxone film will likely remain very high. Even though Zubsolv and Bunavail have been available for some time, the retail cost of these products has not decreased that much.
Zubsolv (Buprenorphine + Naloxone)
Zubsolv is marketed as a tablet that is placed under the tongue. It dissolves easily. Some patients prefer the taste over Suboxone generic tablets and films.
The most common form in use is Zubsolv 5.7 mg Buprenorphine with 1.4 mg Naloxone, … other strengths are difficult to find. This is the preferred drug on some prescription plans.
The tablet is not easy to cut. One can use a tablet cutter to cut it into half but beyond that it is not practical. That makes tapering the dose on the same prescription some what difficult.
Zubsolv tablet is available in four strengths:
- Zubsolv 1.4 mg Buprenorphine with 0.36 mg Naloxone, tablet
- Zubsolv 5.7 mg Buprenorphine with 1.4 mg Naloxone, tablet
- Zubsolv 8.6 mg Buprenorphine with 2.1 mg Naloxone, tablet
- Zubsolv 11.4 mg Buprenorphine with 2.9 mg Naloxone, tablet
Zubsolv has the easiest free trial program that can give you a total of 30 tablets free, it requires printing your own coupon, and is limited to self pay patients, and is once a life time benefit. The provider does not have to fill any forms, a prescription specifically for Zubsolv is required. They have not mentioned any end date. Find the details at the Zubsolv website.
Bunavail (Buprenorphine + Naloxone)
Bunavail is marketed as a film that is applied to the buccal mucosa (the inside of the cheek). Only one side is designed to stick and that is the side that has medications. The medication is absorbed through the buccal mucosa and the film then comes off lose and can be spit out. The manufacturer claims that their formulation is more efficient and more of the medication is absorbed. Bunavail 4.7mg film is equivalent to Suboxone’s 8mg film.
Patients have to learn how to use it, as it is different from other sublingual forms.
Bunavail buccal film is available in three strengths:
- Bunavail 2.1 mg Buprenorphine/0.3 mg Naloxone, film
- Bunavail 4.2 mg Buprenorphine/0.7 mg Naloxone, film
- Bunavail 6.3 mg Buprenorphine/1 mg Naloxone, film
Bunavail buccal film 4.2 mg/0.7 mg is the most commonly available strength. One can stick the film to the inside of cheek and the medication will continue to be absorbed, unlik eother medicatins where you put it under the tongue and hold still waiting for it to be completely absorbed. Unlike other formulations … where you have to wait … can’t swallow, can’t spit till all medication is absorbed (5 to 10 minutes).It also does not come in contact with the tongue so the taste is not a concern.
It has not been popular with my patients, because they wonder if all medication was absorbed from the film or not, and they have the mistaken belief that it is poor value because it has less Buprenorphine.
It is difficult to cut the film therefore trying to taper the dose on a given prescription is difficult.
The manufacturer offers a rebate for both self-pay and insured patients. You can download rebate card from the Bunavail website
Medicare and Medicaid Coverage of Buprenorphine products
I do not see Medicare or Texas Medicaid patients.
Medicare does not cover outpatient addiction treatment. It only covers inpatient detox. However, the medications used for treatment may be covered by Medicare part D, check with your plan.
Texas Medicaid does cover Buprenorphine products prescribed for Opiate Dependence Treatment as listed on page 55 of the preferred drug list published in 2018. The preferred product according to the list is Bunavail and Suboxone, preauthorization is required, and quantity limitations apply. You can only obtain treatment through approved network providers. Each preauthorization lasts 90 days, and has to be reapplied after that.
Buprenorphine is a scheduled III controlled substance.
All four products have been placed under Schedule-III of the controlled substances act, making their prescription and dispensing less cumbersome than most of the opioid medications that are used for the control of pain. However, prescribing these medications requires a special waiver certificate over and above the DEA certificate and registration that is required to prescribe opioid pain medications.
Why is this called a waiver certificate?
According to current laws addiction can only be treated at approved addiction treatment facilities which are licensed by the state and federal government; … by granting this certificate the DEA waives this requirement and allows any ordinary medical provider to provide addiction treatment from their clinics. This certificate can be obtained after doing a short course and acquiring competence in prescribing this medication. Each provider is limited to treat up-to 100 active patients. The provider does not have to be an addiction specialist, most providers are family practice doctors, general internists, psychiatrists, and pain management doctors.
Since 2016 under the Comprehensive Addiction and Recovery Act (CARA), qualified Nurse practitioners and Physician Assistants can also apply for waiver, and prescribe the above medications.
Buprenorphine extended release depot preparations
Sublocade once a month injection
Buprenorphine is now available as a once a month injection under the brand Sublocade. This is not sold in pharmacies and is only available through a medical provider. Sublocade’s approximate cost is $1,600 per monthly dose of either strength.
Excerpt from the FDA notice:
Sublocade is a drug-device combination product that utilizes Buprenorphine and the Atrigel Delivery System in a pre-filled syringe. It is injected by a health care professional (HCP) under the skin (subcutaneously) as a solution, and the delivery system forms a solid deposit, or depot, containing Buprenorphine. After initial formation of the depot, Buprenorphine is released by the breakdown (biodegradation) of the depot. In clinical trials, Sublocade provided sustained therapeutic plasma levels of buprenorphine over the one-month dosing interval.
Probuphine six month implant
Buprenorphine is now also available as an implant called Probuphine. It is designed to provide a constant, low-level dose of buprenorphine for six months.
I do not offer these extended release depot preparations.
You will have to find an approved provider through your insurance network. These long acting preparations are not sold at pharmacies, they are supplied directly to providers who have obtained the necessary approval and training to implant them.
Buprenorphine for Chronic Pain Management
Buprenorphine is an opioid agonist and is approved for the treatment of pain, however only certain formulations are approved. These formulations are very expensive, and are rarely authorized by insurance/prescription plans.
The following formulations are currently being marketed in USA.
Butrans Transdermal Film
Butrans available as 5 to 20mcg/hour dermal patches, applied to the skin. Each patch delivers medication for seven days.
Retail cost of one 20mcg/hour patch is $120. Each patch is supposed to last for seven days, that means a monthly cost of about $460. It requires jumping through a lot of hoops to get it covered by insurance.
A 20mcg/hr patch, according to current MME turns out to be 33.6 MME per day, that is, it is equal to 36mg of Morphine per day. $460 for one month for 36mg of morphine per day is very poor value.
It is only useful for a patient who can not take medications by mouth. Even for those situations a fentanyl transdermal patch has lower cost.
Calculation: 20 mcg/hr Butrans transdermal patch X (4 patches/28 days) X 12.6 = 36 MME/day
Belbuca Buccal Film
Belbuca is available as 75mcg to 900mcg film applied twice a day to the mucosal surface inside the mouth. This is very similar to Bunavail, but without Naloxone.
Most common available form is 300mcg films at a cost of about $10 each. One months supply is about $600. It is not a cost effective alternative to commonly available opioid medications, and most insurances do not cover it.
According to the current MME values, which is very debatable … 300mcg films twice a day gives a Morphine Milligram Equivalent value of 18, that means it will deliver an opioid equivalent of 18mg/day. $600 for one month for 18mg of morphine per day is very poor value.
Its only advantage will be for a patient who can not swallow pills. Even for those situations a fentanyl transdermal patch has lower cost.
Calculation: 300 mcg Belbuca buccal patch X (60 patches/30 days) X 0.03 = 18 MME/day
What is MME?
MME stands for Morphine Milligram Equivalent. It is a value doctors use when converting one opioid to another opioid to guess as to how much should be prescribed. I have not found these values to co-relate well for Buprenorphine products. Another twist to that is upto 2016 Buprenorphine sublingual carried an MME multiplier of 10, miraculously it was increased to 30 in August 2016 by CDC. It is posted on the CMS site here.
In 2017 CDC removed the MME for Buprenorphine containing products that are used for treatment of addiction.
Additional information is available at DailyMed, through US National Library of Medicine,