The use of Suboxone (and other buprenorphine-containing medications) for opioid use disorders is a form of addiction treatment known as medication-assisted treatment (MAT). MAT has been around since the 1930s and has a history of controversy and failures. Suboxone has not been free from this controversy.
Those who are critical of Suboxone use are often heard saying, "You're just trading one addiction for another." Whether they realize this or not, their statement falls under a school of thought known as abstinence-only. The use of MAT, however, is considered harm-reduction, which is another approach to addiction treatment.
The general idea of harm-reduction treatment is that we can minimize the consequences of use if we can't eliminate use altogether. It removes the black-and-white thinking of abstinence-only and acknowledges the difficulties of addiction treatment and recovery.
The usual reply from doctors and therapists to the "trading one addiction for another" comment is that Suboxone is a medication like any other medicine an individual would take for diabetes or high blood pressure. This response is somewhat deflective. It is also problematic. Patients are smart. They catch on to the fact this response doesn't directly address their concerns. This can lead to mistrust and resistance. Patients eligible for Suboxone treatment may elect not to take this medication.
The second problem is there is some truth to the criticism. Yes, this criticism of Suboxone misses the mark, but the patient must understand what is happening chemically in their brain when they are addicted to opioids and when they take Suboxone to avoid noncompliance leading to withdrawal and relapse. As always, psychoeducation is an integral part of treatment. Unfortunately, psychoeducational is often overlooked. If providers fail to educate their patients properly, they leave their patients susceptible to an otherwise, very preventable relapse.
The Brain and General Addictions
Before understanding how Suboxone is used, a basic (and maybe simplified) understanding of how parts of the brain function is important.
The brain is a fatty organ comprised of nerves and nerve endings called neurons. The neurons are covered in transmitters and receptors. Transmitters release chemicals called neurotransmitters which bind to the receptors. Each different type of neurotransmitter has a different responsibility for carrying out various functions of the brain and body.
Transmitters, receptors, and neurotransmitters are not one-size-fits-all. Specific receptors bind to the specific chemical structures of individual neurotransmitters. Some of these neurotransmitters, such as dopamine and serotonin, cause feelings of pleasure when they are released. Activities an individual might enjoy such as reading, riding a bike, or laying out in the sun will release a normal amount of dopamine.
When an individual uses a drug such as alcohol, cocaine, or methamphetamine they might enjoy a greater sense of pleasure compared to any other experience they have ever had. This is a result of dopamine flooding the brain. Human beings are generally geared to seek pleasure for survival purposes. As a result, they will continue to pursue this experience. However, the brain does not like to be flooded with dopamine.
The brain and the rest of the body constantly seek homeostasis, a biological balance. A well-known example of this is the tendency to sweat to bring down body temperature when overheated. When too much dopamine is produced, homeostasis is achieved by shutting off the mechanisms responsible for creating, releasing, and catching dopamine.
This unfortunately is the root of addiction. With less dopamine, moods decrease. Reading, riding a bike, and laying out in the sun no longer provide the enjoyment they used to. These activities leave people feeling less than their usual selves. Their normal drug use may only bring them back up to their baseline moods. To get the full experience of when they first started using, they have to increase the amount of the drug that they use.
When they use more of their drug, their brain is flooded again with dopamine. This dopamine flood leads to another reduction in the dopamine production mechanisms. The user's moods decrease again. They must now increase their drug use again, and the cycle repeats.
The Brain and Opioid Addiction
Another type of neurotransmitter found in the brain is opioids. One example would be, endorphins, often referred to when people speak of a "runner's high." When opioids bind into opioid receptors they act differently than most other neurotransmitters. Instead of passing information from one neuron to the next, they slow information down. This stops pain.
Therefore, someone with an injury may be prescribed painkillers from a class of medications also called opioids as they are a synthesized version of what is found in the brain. Taking opioid painkillers floods the brain with opioids. Opioid users can quickly find themselves in a similar cycle of having to take more and more painkillers to get the painkilling effect or the high they were chasing.
Opioids are more than just pills though. They can be powders or liquids. They have names such as oxycodone, hydrocodone, and fentanyl. There are also opiates. Opiates are the natural versions created from the poppy plant. Opiates include heroin, morphine, opium, and codeine. People may start using opioid painkillers when they are prescribed due to an injury or painful illness. Some start for purely recreational purposes. Regardless of their reason for starting, tolerance can quickly build. The user becomes hooked.
In the case of a patient taking medication to manage pain, their tolerance may reach a limit with their doctor. The doctor may refuse to increase or order refills of the prescription. When the user cannot get enough of their drug, their moods become unstable. They become irritable and difficult to get along with. They may experience withdrawal. In a sense, withdrawal is the opposite of opioid use. Opioids slow messages. Now the messages speed up. Old pain returns. New pain makes its presence known. The heart races, breathing becomes rapid and shallow, the digestive tract speeds up causing diarrhea, and nerves throughout the body begin firing off causing nausea, vomiting, and an overall feeling of anxiety.
As mentioned above, humans seek pleasure. Withdrawals are not a pleasant feeling. Users will seek opioids anywhere they can find them. This can become costly. Previously the user could pay about $10 or $20 on a copay and receive 30, 60, or 90 pills every month. Now they may pay $10 per pill.
To offset the costs, users will sell belongings, neglect bills, buy fewer groceries, pawn stolen items, sell the drug themselves and even turn to prostitution. Now, not everyone who uses or becomes addicted to opioids will display any or all of these behaviors. When someone is behaving this way, though, it all has to do with affording the habit. These behaviors can obviously lead to relationship, legal, and housing issues.
Treating Opioid Addiction with Suboxone/Buprenorphine
When an individual is ready to overcome their opioid addiction, they may go see a doctor who will prescribe buprenorphine. Buprenorphine is found in Subutex, Sublocade, and perhaps in the most well-known form of Suboxone. Suboxone also contains another medication, naloxone. Naloxone is an opioid blocker or opioid antagonist. If someone uses Suboxone and then takes another form of opioids, the opioids will not reach the receptors because of the naloxone.
Buprenorphine is a partial opioid or opioid agonist. It works by binding onto the opioid receptor in the brain and mimicking other opioids. When this happens, it slows down the messages just like any other opioid. This means the heart rate and breathing return to normal. Pain goes away. Withdrawal symptoms are avoided.
Buprenorphine may cause some intoxicating feelings when first starting a regimen. These are usually mild and go away after a week. Most people don't experience them at all. Buprenorphine also has a ceiling. This means when an individual reaches a therapeutic dose, taking more will do nothing for them. As a result, buprenorphine abuse and overdoses are significantly lower than its opioid counterparts. This ceiling effect also means tolerance does not build.
The absence of a tolerance build-up also means the medication stays affordable. There is no need to engage in unlawful or otherwise damaging behaviors. Relationships are protected. Many users state that taking buprenorphine allows them to feel normal, but not all is perfect.
Suddenly stopping or decreasing the dose of buprenorphine will cause withdrawal symptoms. Once again, the opioid receptors will have nothing binding onto them. This brings back the original criticism. Suboxone users have traded one addiction for another. Yes, this is true. It is important to remember the brain has depleted its ability to fill its opioid receptors on its own.
Now here is where the criticism misses its mark. This addiction to buprenorphine is arguably a good thing. Buprenorphine is safer as a result of its ceiling. The prescribed patient does not seek opioids in painkillers or heroin or elsewhere. Buprenorphine carries out a function that allows the brain to operate normally. Remember, those receptors need something to bind to.
Many patients are successful with buprenorphine. They do not relapse in the same way individuals with other types of addictions do. In a sense, it is because the buprenorphine satisfies the needs of the addiction. Someone struggling with alcohol addiction may play a mental tug-o-war with themselves when they begin thinking about alcohol. They argue with themselves if they are going to cave into their cravings or not. Some days they win this argument. Some days they lose and relapse.
The mental tug-o-war is stressful. The quickest way to end it is to relapse. While drinking, the person with alcoholism is at peace. They may have consequences later, but while they are at the bar they are enjoying their drinks. They are not thinking about their next drink. They are thinking about the beer in their hand. Clients on buprenorphine are experiencing the same thing. They are not thinking about finding a painkiller or more heroin. They have the effects already in their brains, specifically, their opioid receptors.
The human body needs those receptors activated as much as it needs the heart to beat or the lungs to breathe. Abstinence-only does not address this need. It leads to relapse. So people have a choice. They can take opioid painkillers or buprenorphine. There is a clear advantage with buprenorphine. Once again, users are still addicted. They have traded addictions, but one of these addictions does not come with the unwanted legal, emotional, social, and relationship behaviors of the other.
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