Long-Term Effects of Suboxone

A note from a reader with a question about Suboxone:

Suboxone has really worked for me in getting off vicodin.But I have been unable to stop taking Suboxone.It occurred to me recently that this may turn into a lifelong dependency.If so, what are the long-term side effects of Suboxone?

Thanks so much,

My Answer:

Suboxone really is best thought of as a long-term, perhaps life-long medication.Your attachment to pain pills will in all likelihood be life-long as well; most people who stop Suboxone are surprised at the cravings for opiates that they have.I don’t think Suboxone increases the cravings at all, but rather it is just so effective at eliminating them that people forget how attached to opiates they once were.I generally recommend that people stay on Suboxone ‘forever’, or until something better comes around– they are much safer on Suboxone, as it helps them avoid an impulsive relapse that can put them in jail, kill them, etc…

We do not know of many long term effects from Suboxone.Long term opiate use in general can lower testosterone levels in men and cause things from that, like reduced sex drive and I suppose even infertility.I assume that buprenorphine will do the same.There are the other short-term side effects that over time become long-term side effects– dry mouth (which long-term can cause an increase in tooth decay), constipation (which could lead to hemorrhoids, diverticulitis, anal fissures or peri-rectal abscess), sweating (which could lead to… problems dating?). The opiate antagonist naltrexone can cause liver damage, and it is related to naloxone, which is a component of Suboxone– in general the naloxone does not get absorbed, and so the chance of liver damage is likely minimal.It may be a good idea to check a set of labs once per year, though, to check the liver, kidneys, thyroid, and blood cell system, just for safety’s sake.

Probably the worst thing about long-term use is that some docs insist upon keeping everyone on Suboxone in endless therapy.I do not think that therapy is generally required, and I do not think that ‘forced therapy’ is very helpful.But it is hard to find a doc who will treat with Suboxone as they would treat with any other treatment for a chronic condition– that is, to prescribe the medication without placing a number of other requirements on the person.

I hope that answers your questions–

Take care,

J

I’m Not Like ‘Those People’

A recent letter and response that addresses the ‘terminal uniqueness’ issue:

Hi and thx for getting back to me. I have never tried anything to get off of these pills. I am not your stereotypical addict. Truth be told I have never been addicted in my life. I feel like such a loser for letting myself get out of control and if it was not for being sick I would have licked this a long time ago! I am not off them right now because I cant. I work hard all day to support my family and there is no time to be down and out. I have also suffered an incredible string of losses over the past two years. What a predicament huh? I lost my wife two years ago, and the story goes on. I have chronic back pain from degenerative discs, but I will deal with that. Will suboxone do anything for me?

My response:

I have a couple things to say that may come across as ‘brutally honest’—don’t take it personally, but rather understand that EVERY person who gets stuck on opiates has a unique story, and we all were reluctant to see ourselves as ‘stereotypical addicts’. There is a term in addiction—‘terminal uniqueness’—that refers to a state of mind that is common with addiction, and which keeps people sick.

A frequent refrain by a person new to a treatment center is ‘I’m not like those people’. The fact of the matter is that one rarely sees a ‘stereotypical addict’ at treatment. What one sees are teachers, dentists, single and married moms, college students, high school students, people with back problems or fibromyalgia, people who have been through terrible tragedies… So try to avoid seeing the things that make you unique. Instead, try to see the things that make you like everyone else—the horrible feeling of being trapped by something, when you have always handled things well up until now. That is how most people who are stuck on opiates feel—trapped, embarrassed, ashamed, angry… and afraid. Others don’t feel anything because they repress all of their feelings and put up a fake, cocky exterior. That is what denial is all about.

J

Is Suboxone At Odds With Traditional Recovery?

By now almost every opiate addict has heard of Suboxone, a medication for opiate dependence that has been around for about ten years. I admit to mixed feelings about Suboxone based on what I have seen and heard while treating well over 100 patients over the past two years. I also acknowledge that my opinions are likely influenced by my own experiences as an addict in traditional recovery.While Suboxone has opened a new frontier of treatment for opiate addiction, it also threatens to split the recovering and treatment communities along opposing battle lines.Such and outcome would be a huge missed opportunity to improve the lives of opiate addicts.

An amazing medication

For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.In this article I will use the name ‘Suboxone’ because of the common reference to the drug, but in all cases I am referring to the use and actions of buprenorphine in either form.The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose.Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior.Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opiate.

Different treatment approaches

At the present time there are significant differences between the treatment approaches of those who use Suboxone versus those who use a non-medicated 12-step-based approach. People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking Suboxone as having an ’inferior’ form of recovery, or no recovery at all. This leaves Suboxone patients to go to Narcotics Anonymous and hide their use of Suboxone. On one hand, good boundaries include the right to keeping one’s private medical information so one’s self. But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of Suboxone is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’;they are not in a good position to deal with even more shame coming from other addicts themselves!

An ideal program will combine the benefits of 12-step programs with the benefits of the use of Suboxone.The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable. If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other.But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.Success rates for long-term sobriety are lower for opiates than for other substances. This may be because the ‘high’ from opiate use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town. The ‘high’ of opiate use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.The term ‘denial’ fits nobody better than the active opiate user, particularly when seen as the mnemonic:Don’t Even Notice I Am Lying.

The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opiate addiction.

Drug obsession and character defects

Suboxone has given us a new paradigm for treatment which I refer to as the ‘remission model’. This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed. To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time. Opiate addicts have a number of such ‘defects.’The dishonesty that occurs during active opiate addiction, for example, far surpasses similar defects from other substances, in my opinion.Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career. The addict becomes more and more self-centered, and the opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.The active addict learns to blame others for his/her own misery, and eventually their irritability results in loss of jobs and relationships.

The traditional view holds that these character defects do not simply go away when the addict stops using. People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.I had such an expectation when I first began treating opiate addicts with Suboxone—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user. I realize now that I was making the assumption that character defects were relatively static—that they developed slowly over time, and so could only be removed through a great deal of time and hard work. The most surprising part of my experience in treating people with Suboxone has been that the defects in fact are not ‘static’, but rather they are quite dynamic. I have come to believe that the difference between Suboxone treatment and a patient in a ‘dry drunk’ is that the Suboxone-treated patient has been freed from the obsession to use.A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking. People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.Such is the case with opiates as well—the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair. With this in mind, I now view character defects as features that develop in response to the obsession to use a substance. When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with Suboxone.

In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice. For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system. The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean. While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle. The successful addict will view the substance with fear—a primitive emotion from the old brain. When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade. For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.

The dynamic nature of personality

My experiences with Suboxone have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic. Suboxone removes the obsession to use almost immediately. The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside. The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved.  I base this opinion on my experiences with scores of Suboxone patients, and more importantly with the spouses, parents, and children of Suboxone patients.I have seen multiple instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found Suboxone treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.

A natural question is why character defects would simply disappear when the obsession to use is lifted? Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.

Combining suboxone treatment and traditional recovery

Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between Suboxone and traditional recovery becomes clear.  Should people taking Suboxone attend NA or AA?Yes, if they want to.A 12-step program has much to offer an addict, or anyone for that matter. But I see little use in forced or coerced attendance at meetings. The recovery message requires a level of acceptance that comes about during desperate times, and people on Suboxone do not feel desperate.In fact, people on Suboxone often report that ‘they feel normal for the first time in their lives’. A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.

The role of ‘desperation’ should be addressed at this time: In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character. Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.

Other Questions (and answers):

-Should Suboxone patients be in a recovery group?

I have similar reservations about forced attendance, but there is something to be gained from the sense of support that a good group can provide.

-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power? Are these steps critical to the resolution of character defects?

These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.But for a person taking Suboxone I see the steps as valuable, but not essential.

-Where does methadone fit in?

Methadone is an opiate agonist. A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.With cravings comes the obsession to use and the associated character defects.This explains the profound difference in the subjective experiences of addicts maintained on Suboxone versus methadone, and explains why in my practice I have many patients who have switched to Suboxone, but none in the other direction.

The downside of Suboxone

Practitioners in traditional AODA treatment programs will see Suboxone as at best a mixed blessing. Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe Suboxone. Suboxone is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety. Suboxone itself can be abused for short periods of time, until tolerance develops to the drug. Snorting Suboxone reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.Finally, the remission model of Suboxone use implies long term use of the drug.Chronic use of any opiate, including Suboxone, has the potential for negative effects on testosterone levels and sexual function, and the use of Suboxone is complicated when surgery is necessary. Short- or moderate-term use of Suboxone raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.

The beginning of the future

Time will tell whether or not Suboxone will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other. The good news is that treatment of opiate addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.Some day we will likely look back on Suboxone as the beginning of new age of addiction treatment.But for now, the treatment community would be best served by recognizing each others’ strengths, rather than pointing out weaknesses.

This article can be reproduced freely as long as the following attribution is included:

The author, Jeffrey T. Junig MD PhD is a psychiatrist in solo practice in Wisconsin, and is Asst Clinical Professor of Psychiatry at the Medical College of Wisconsin.  Read more about suboxone at SuboxForum.com, AddictionRemission, or at Suboxone Talk Zone. He can be contacted at Fond du Lac Psychiatry.

Question From Anonymous

I am going to move this question to a new post so that everyone can read it:

hi,

i am in recoverery and was injured, was on percocets for about three months. i kinds detoxed with a lower dose of opiates but then took a few days worth again after a hard weekend. a few days later the wd symptoms came right back! oh, i couldn’t take it so i asked my doctor for suboxone. he knew nothing about it and wanted to give me yet more opiates. after a lot of convincing he gave me 2 mg tabs/30 days worth. I want to be done with all this stuff asap- so what’s your suggestion as to how to take this just to make it through the wd’s from the opiates? thanks!

My Answer:

This question illustrates a number of points. The first point is that opiate addiction is a life-long illness. Anonymous does not say how long he or she has been ‘in recovery’, but for the most part it does not matter; people who have been clean for years or even decades will find themselves brought instantly back to the mess they thought they left behind, after just a percocet or two. As addiction is a conditioned, or learned, process, it makes sense; If I take you back to your childhood neighborhood after twenty years away, you will likely be able to find your way around without difficulty. Unfortunately we cannot erase conditioned behavior any more than we can intentionally forget bad memories.

A second point concerns the nature of withdrawal. I am convinced that the intensity of withdrawal is more related to the intensity of prior withdrawals than to the amount of drug used. I have heard people describe very severe withdrawal after minimal relapse. There is a term in medicine– ‘kindling’– which describes how CNS symptoms such as seizures become worse each time they occur. I have found that withdrawal is similar.

A third issue is the legality of prescribing opiates. It is illegal for anyone to prescribe a narcotic for the purpose of avoiding withdrawal, with the exception of certified methadone clinics or suboxone prescribers. It is illegal for a pain physician to taper a person off opiates to avoid withdrawal; it is illegal for a family practice doc to prescribe vicodin to avoid withdrawal. A family practice doc can prescribe suboxone for pain, but cannot prescribe suboxone for addiction UNLESS the doc is suboxone certified.

As for answers, My first question would be, what is/was the nature of your recovery? If you are involved in AA or NA, I recommend stopping the opiates and getting to a meeting, and then hitting as many meetings as you can for the next few months. If you hope to be opiate-free again, your best bet is to just stop using, and take the withdrawal.

If, on the other hand, your recovery was a bit ‘shaky’, or if you always had intense cravings, or if you just cannot stop using (God forbid that you have found a source of opiates), you may want to consider suboxone. Many people find that after years of being clean they still felt like an opiate addict just hanging on…. those people will often feel ‘normal’ for the first time when they take suboxone. In such a case, though, you would likely end up taking suboxone for a long time– perhaps for the rest of your life.

Suboxone can be used to taper off of opiates, but it is most useful in this regard for coming off of high doses of methadone, which is extremely difficult to do. Suboxone (buprenorphine) is a very potent opiate– much more potent than oxycodone– and so it is probably as easy or even easier to come off oxycodone than to come off suboxone. The problem is that just coming off the opiate, as tough as it seems right now, is really the easy part. The hard part is staying off of opiates, as you found after your ‘tough weekend’. If you do not have a good program going on in AA or NA, then you really may want to consider suboxone. It will prevent relapse and put your addiction into remission with a minimum of pain or discomfort. But again, this is a long term proposition– just as opiate dependence is a long term illness.

Runny Nose, Back Pain, Withdrawal in New Patient

This new patient has been on suboxone for two weeks, and reports having low back pain and a runny nose. He also feels that the 16 mg dose of Suboxone that he takes in the morning wears off by the end of the day. You can read my answer, and feel free to add your own experiences or suggestions:

Hi XXXXXXX,

I received your message.A couple thoughts…As far as pain goes, the suboxone has the analgesic potency of about 30 mg of methadone or about 50-60 mg of oxycodone.Your best bet, with or without Suboxone, is to avoid treating back pain with opiates– that is a dead end street with a pile of messed up lives at the end of it.It may be that you were treating aches and pains that you didn’t know that you had– often people on opiates will hurt their backs, knees, whatever, without knowing it, and continue to do more and more damage without the usual warning that our bodies give us (as pain).If you try to treat back pain with opiates long term, the tolerance requires higher and higher doses of meds, and the patients gets more and more messed up by the obsession for opiates.

Treatment for your back should include 1) rehabilitation either through physical therapy or by your own exercise and stretching routine, 2) anti-inflammatory medication like ibuprofen or naprosyn (over the counter as aleve), 3) avoid re-injury by learning correct lifting technique and avoiding certain things that you know will aggravate it, 4)ice after over-use, heat to loosen muscles at night, 5) getting enough sleep, and avoiding things that cause muscle spasm like caffeine, opiates, and alcohol.

Runny nose… that is sometimes a symptom of withdrawal. That along with your other questions suggests that your tolerance is higher than the opiate effect of suboxone. Give it time, and it will go away– if it is still there after a couple weeks I would start to think it is something else, like a virus.As far as the meds ‘wearing off’, I have had the benefit of seeing the pharmacologic data on the drug buprenorphine when I was doing my ‘treatment advocate’ training with the company. The drug lasts forever in us humans– when a person stops taking subox the ‘real withdrawal’ doesn’t hit for 3-5 days.In your case, you are likely feeling a combination of things. First, as I said in the prior paragraph, you are having mild withdrawal from ‘mismatch’ between your tolerance and the Suboxone– this will resolve soon. Second, it is not uncommon for people to have full- blown withdrawal symptoms that come from our brains ‘replaying’ our earlier withdrawals. Usually the more we focus on them, the worse they become. They will fade away as your tolerance adjusts– by the time I see you again they should be gone. In the meantime try to keep busy and distract yourself as soon as you sense them coming, or if they come at a certain time each day try to keep busy at that time. More Suboxone will not help, because of the ceiling effect of the drug– your receptors are all bound up at 8-16 mg/day.

J

New Patient Having Nausea

Nausea is not uncommon in patients starting Suboxone. Please read what I wrote to this patient:

Nausea usually comes about if the opiate effect of the suboxone is stronger than what you were used to. Reduce the dose to half a pill per day– that will be enough to prevent withdrawal (even a quarter of a pill per day will prevent withdrawal), but hopefully won’t be so much that you get sick. Once you tolerate that dose, you can slowly increase every few days to the full amount.

Sometimes the nausea comes from the naloxone, and we have to go with subutex– but subutex is more expensive and less available. Usually reducing the dose does the trick. The nausea is almost always gone after 4-5 days. I could prescribe a med to reduce nausea– send me the phone number of a pharmacy if you want me to call in compazine. That med will make you sleepy, though, and has other potential side effects. For example, it can make your muscles twitch without your ability to control them (the symptoms go away after the drug wears off, in about 6 hours).

Again, send me a pharmacy phone number if you like, or otherwise give it a couple days at the reduced dose.

J

Let’s Talk

One of the comments I hear the most from suboxone piatients that they had their own group– a place to talk about addiction issues, frustrations, inspirations, etc, without the need to hide their use of suboxone. Many suboxone patients attend AA or NA for the fellowship, but are held back from complete honesty for fear of being ostracized (a valid fear).

My hope is that suboxone patients will use this site to discuss their experiences, hopes, and frustrations in a positive way. This is not a forum to debate whether or not suboxone is a wonder drug or the work of the devil, as there are already plenty of sites dedicated to particularly the latter opinion. But for those patients who are taking suboxone to induce remission of opiate addiction, who prefer the stability and normal mind that comes from suboxone maintenance over the chains of active opiate addiction, please use this space to tell your story, to ask questions, to post answers, or to just say ‘hello’.

To comment on a topic, click on the word ‘comments’. At the present time I do not plan to moderate what is written. If you would like to author an article, send an e-mail to drj at suboxonetalkzone.

And of course, be sure to visit us at ‘the Forum’!