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Why the Naloxone?


why the naloxone?  photo credit belowI will take a moment to clarify the difference between the two major forms of buprenorphine on the market, namely Suboxone and Subutex.

Suboxone is a medication that contains buprenorphine plus naloxone,

30 thoughts on “Why the Naloxone?

  • August 3, 2011 at 6:46 pm

    I know you say that “most” of the naloxone would be destroyed by the “first pass”–but I have heard from certain patients and sources that in some cases, people get either an antsy, restless feeling from Suboxone, or they feel depressed while on it, which makes me wonder if even the minute amount of naloxone that might get through this first pass could be affecting the endorphin levels in the brain?

    Reply
    • August 5, 2011 at 1:34 pm

      I’m hesitant to attribute that to naloxone. I do recognize that the enzymes that break down naloxone are blocked by a number of relatively common meds– but even in those cases, naloxone is a very short-lived med in the body. Those minute amounts that ARE absorbed would certainly be gone within an hour or two. But if a person was feeling antsy ONLY in the 2 hours after each dose, I would accept that as evidence for a naloxone effect.

      Buprenorphine itself has actions at kappa opioid receptors. Much less is known about THOSE actions and effects– so that may be a source of those side effects as well. Thank you for your comments!

      Reply
  • August 6, 2011 at 2:55 am

    Thanks for explaining the whole naloxone issue. Perhaps you could help educate the moron giving his opinion in this article: http://www.fosters.com/apps/pbcs.dll/article?AID=/20110731/GJNEWS_01/707319919/-1/FOSNEWS

    A Dr. Terry Bennett is claiming that naloxone counters the high you would get from straight buprenorphine and that this is why it’s added to the drug in Suboxone. It’s sad and frustrating when physicians are so ignorant about a medication they specialize in prescribing. Especially when they share that ignorance with the public through the media like it’s fact. Makes my toes curl…

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    • August 7, 2011 at 6:14 pm

      I hear this comment from physicians all the time– even from people prescribing Suboxone or buprenorphine. Luckily the ignorance has little consequence… but I get annoyed as well. It is a form of intellectual imprecision… but I suppose we all have occasional area where our writing outstrips our knowledge– myself included.

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  • May 9, 2015 at 7:03 am

    Thank u..u are very helpful

    Reply
  • November 6, 2015 at 6:42 pm

    Doctor my doctor will not prescribe me subutex and I have never used intravenously. I was a pill popper. I also feel not so well on suboxone and soon I will not have insurance and it would be less expensive for me to get the generic buprenophine. Im in Southern NJ. Do you know of any docs in this area that would prescribe subutex?
    Thanks

    Reply
    • November 8, 2015 at 10:51 am

      No- I don’t know the individuals who prescribe buprenorphine in your area. Unfortunately, there is a huge amount of ignorance about buprenorphine among physicians, to the point where the lawmakers have bought into that ignorance. There are so many facts that must be ignored, in order to maintain their state of ignorance, that I wonder if they have ANY understanding of buprenorphine! A few examples:

      Anyone who knows what ‘binding affinity’ means– i.e. anyone who reads any amount of pharmacology– would question the entire premise behind adding naloxone to buprenorphine. First, buprenorphine has much greater binding affinity than naloxone, to the point where naloxone would not be expected to displace buprenorphine from mu receptors. And there are, in fact, a number of clinical studies showing that naloxone does not precipitate withdrawal from buprenorphine. Second, if if it did, naloxone is a very short-acting medication. Even if it did cause blockade, that block would be gone in 20 minutes– and the buprenorphine would be around for the next 24 hours!

      So naloxone does nothing to change buprenorphine, no matter how buprenorphine is used. Another issue– ALL of the properties of ‘Suboxone’ are due to buprenorphine itself– the ceiling on mu effects and on respiratory depression, the properties that make it useful for treating addiction— those things are all present in buprenorphine alone.

      Some docs say ‘plain buprenorphine is just like heroin.’ But does heroin precipitate withdrawal when taken after other opioids? (buprenorphine does). Does heroin have a cap to effects at mu receptors? (buprenorphine does). Does heroin cause overdose deaths? (buprenorphine almost never does. About 40 people die each year with some amount of buprenorphine in the bloodstream– the same as the number of people who die from lightning. And in MOST of those cases, the buprenorphine was not a factor in the death– and would have PREVENTED the death if MORE was in the bloodstream!!).

      It is difficult to even imagine a way to abuse buprenorphine. If an active addict takes it, the med will cause withdrawal. If a non-addict uses it as a ‘gateway drug’ (there is no evidence that happens, btw) that person would be tolerant to buprenorphine after a few days, and at that point it would be impossible to get a ‘buzz’ from buprenorphine or from any other opioids!

      I am frustrated because of the waste of resouces… since buprenorphine is cheap, and acts just like the combination products. But many docs get stuck on this issue. I assume their inability to reason on the issue comes from the stigma over addiction; the idea that addicts need to be controlled or trusted, and ANY request must be taken as a sign of bad behavior.

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      • December 24, 2017 at 1:39 pm

        Thanks for the straight forward correct information. My addiction doctor explains nothing. Just writes scripts and a smile.so I’ve been taking naloxone (in Suboxone) for a long time for no reason. I’ve a question then, is there any known health risks with taking naloxone everyday for very long periods of time?

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  • January 18, 2016 at 6:23 am

    Hi, you’re absolutely right..I live in TN and have been in treatment for 1 year, taking subutex as suboxone caused massive headaches for me. Now the dumb lawmakers have made it near impossible to get subutex, and I have to switch to suboxone. I’m afraid the headaches, along with me not being able to afford suboxone, will lead to my relapse after a year of sobriety. What should I do?

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  • February 3, 2016 at 5:31 pm

    DR. You are wrong, you have it backwards. The Buphrenorphine in Subutex and Suboxone is in a hydrochoride form(HCL) which with alkaloids is the water soluble form. When an alkaloid is in a base form it is called a “free base” and is then fat soluble. Naloxone is fat soluble to will not pass through the capillaries in the mouth without a lipid carrier. Crack cocaine for example is an alkaloid that has been put in to its free base form or alkaline ph and is why dealers can hold pieces of crack in their mouth all day and it wont dissolve, where in its powder form its a HCL and can be snorted. Naloxone is fat soluble and will be absorbed if swallowed.

    Reply
    • February 3, 2016 at 7:54 pm

      Damn, a little knowledge is such a dangerous thing… I have a PhD in neurochemistry. I’m not trying to brag– I’m just trying to help you realize that I know something about acid/base reactions. I don’t want to waste the time to explain all of the things you wrote the make no sense…. but the idea of a ‘lipid carrier’ for example, is simply ridiculous. Lipids don’t ‘carry’ polar molecules across nonpolar membranes. But you write SO many other things that are just silly– ‘Naloxone is fat soluble to will not pass through capillaries in the mouth without a lipid carrier’. Huh? Naloxone is a polar molecule. About 3% crosses into capillaries in mucosal epithelium.

      Naloxone doesn’t cross mucosal epithelium in signicant amounts at physiologic pH. 97% of a typical dose of naloxone is swallowed, and absorbed in the small intestine through carrier-assisted processes— the same transport processes that absorb polar molecules like amino acids. But absorption of naloxone doesn’t matter– as it is destroyed by first-pass metabolism at the liver, after being transported there by the portal vein. I don’t know if you are getting confused between naloxone and naltrexone, or if you are just trying to build an education through blue light posts… but I can assure you that I know about free bases and alkaloids. By the way, another nonsense comment is that ‘alkaloids in base form are called free base’. Being an alkaloid has nothing at all to do with whether a weak acid is in a polar form, or in it’s free base form. That concept applies to all weak acids– and has nothing to do with ‘alkaloids’.

      I wouldn’t normally bother to point all this out; I’d just let you pretend to know what you are talking about, and spend my time watching a Seinfeld rerun. But to say I’m wrong– and then write a bunch of nonsense– is just a bizarre thing to do. You need to find a hobby that you understand a little better. Sorry– but someone had to say it.

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  • February 15, 2016 at 10:40 pm

    Hello Dr. I want to start off by saying what an absolute pleasure it was to come across this post and how intrigued I became upon reading because it then led me to the SuboxForum site and i have now become a member, am working on my first post and just cannot get enough of it. And also let me say I can’t help but get a comical kick out of your reply to the previous comment from shaymus regarding how you were just wrong and they then went on an extended response trying to explain further. Your professional yet snappy response is what sold me on you. I just wanted to take the time to respond to you & this post first & foremost because it was here and reading this that sparked my interest in you and your knowledge and expertise regarding the suboxone/subutex world of treatment. I myself have just started taking suboxone and have embarked on a lengthy but certain road to recovery. I have some issues with my

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  • February 15, 2016 at 11:28 pm

    Please forgive me I mistakingly hit the submit comment button before finishing. But to continue where I left off. I have just began my road of recovery and am having some issues with my medication which has sparked quite a few questions about the naloxone ingredient and possible allergies, sensitivity, so on and so forth. I am writing my first post on the forum to introduce myself and then inquire about these symptoms and to see if I can hopefully get some answers regarding them. I decided to turn to the forum with my issues. With the members and all of there experience I know I will be able to get some educated responses to my concerns and hopefully make some new friends in the process. I can only begin to imagine just how busy of a man you must be, but if you are able to maybe find the time to take a look at my initial post and possibly give me any advice you may have regarding the questions and concerns I aim to ask about, it would be so greatly appreciated. And if not able to then no problems sir. I know with all of the knowledge and experience of the fellow members i will surely be able to get some meaningful responses and guidance towards my questions and concerns i have and moving forward with my recovery. Again let me finish this with saying sir, just how very much impressed I was and am with you and your expertise, and how much I look forward to exploring the forum in depth and meeting more people like myself who are on the same roads to recovery. Thank you very much Dr. and hope to hear from you soon. Take care.

    Reply
    • February 15, 2016 at 11:43 pm

      Thank you for your comment and your support– and for finding the forum. Sometimes I’m a bit too ‘snappy’, I know. But given the number of deaths caused by overdose, and safety record of buprenorphine, I get angry when people don’t get at least a fair comparison of their options. I’ll send an email your way so you can contact me directly– and thanks again.

      Reply
  • February 27, 2016 at 12:04 pm

    What’s up Doc?

    Would you please care to explain how much money does a doctor (why is he/she getting paid is a no brainer) in the US per patient per perscription? Just a question over the pond, because I am aware of the pharmacological buisness in the EU. Quite punishible by a fierce mob of people with buckets of tar and plucked feathers… Because it’s guarded by massive loopholes in law.

    I loved your writings on hows/ifs/causes and joys of Suboxone paired ‘main’ ingridients, and forgive me for saying this – they are irevelent. As a long lived addict and user of legal/illegal drugs of plenty yet considering myself more of a tourist, came to a conclusion my doctor in Croatia put me on an even more dangerous path that I have been on before, when pillpoping, snorting and injecting ‘vitamins’. I know for a fact The Doctor is now, more of a Buisness-man, even further I’d love to say a legal drug dealer to the masses – simply because of one minor detail: there is this rather suspicious and enormous lack of the illegal substance Suboxone is used to cure from, while on their path to get straight, people rather sell than use this god-awful treatment drug.
    Yes, it can be injected and it’s more harmful than heroin itself, and by justifing that there are no overdoses when on Suboxone is not a positive notion. But, I digressed too much and with rusty english at that, so please forgive me for being so blunt in this rant.

    All the best to you in your work, your patients in their paths of recovery and all that jazz. Godspeed from Croatia.

    Reply
    • February 27, 2016 at 1:02 pm

      I have a hard time understanding some of your questions, probably because of the language issue. I can’t be critical of your English, of course, as I know absolutely no Croatian– if that is even the language spoken there.

      I’ve also stopped answering all of the silly comments about ‘Suboxone being more harmful than heroin’. That is simply nonsense, and I’m convinced that the truth of the proper way to approach addiction is finally breaking through. Too bad it has taken the deaths of several hundred thousand US people for it to happen– but finally people are looking at the research, and realizing that ‘abstinence based treatment’– where 95% of patients relapse within 1 year, and almost all relapse eventually– is not good enough. I can’t speak for Croatia, but in the US, we are getting closer to getting it right– as I see more articles in the NYT or other mainstream publications pointing out that addiction is a disease, and should be treated like any other disease. Nobody questions why someone with asthma or hypertension or diabetes or Crohns or depression or bipolar takes medication for life. Somewhere, for some reason, addiction became treated differently– I suspect because of the huge profits made by the abstinence treatment lobby– which far dwarf the money spent on medication-assisted treatment. I treat people with buprenorphine at a cost of $70 per month, plus the cost of medication– which ranges from $30 per month for a low dose of buprenorphine, to $600 per month for 16 mg of Suboxone film per day (usually covered by insurance). So do the math– that’s $1000 to $7000 per year for a treatment that works. You could instead go to 2-3 months of residential treatment, and pay $60,000 or more… and there you would have a 95% chance or relapse within a year. Your odds would improve if you continue meetings each week, forever. Most people eventually stop meetings, and relapse. That’s what happened to me, by the way, in 1999, after 7 years of sobriety, when I stopped going to meetings once or twice per week.

      I don’t know if you are actually asking ‘how much docs are paid per prescription’? That is a very ridiculous question. I would ask you— how many space aliens live in your town? The two questions are based in about the same amount of knowledge and paranoia. I don’t know if your question is a joke, or a language issue, or serious. Doctors in the US are never paid for writing prescriptions. In fact, doctors cannot receive any money from pharma except payment for work that they do for them, paid in reasonable amounts limited by the government. I was paid money from several companies between about 2008 and 2012– about $20,000 per year (a few thousand dollars from each company I worked for). George Soros has a web site where he makes a big deal of ‘pharma payments to doctors!!’… and people seem to love getting their undies in a bundle over that stuff. But it was for WORK– for helping their marketing people write copy that is accurate about how the medication works, giving talks to doctors in remote locations who never used the medication and wanted input on how the medication works, helping with training of their sales staff by teaching them how to speak with doctors about the science behind the drug… I received a total of about $800 from the manufacturer of Suboxone over a couple years. Now that I have a busy practice I don’t do any of those things, as they pay very poorly for the hours work you have to put in, compared to clinical medical care.

      I no longer see sales reps, just because I don’t have the time. But when I did, they were always so careful to avoid getting accused of giving a ‘gift’– so they would come back to the office if they accidentally forgot their pen! If they brought a cup of coffee from Starbucks, the doc had to sign a form documenting it. There are plenty of areas in medicine where people make money off bad treatments– and you can read about them on my other blog, or on this one. The current drug testing explosion is one of them that I wrote about recently.

      As for harm from buprenorphine, you just keep on hoping for that, and I’ll keep on saving lives. Buprenorphine has been used for 40 years for pain, and for 15 years for addiction– and there are no safety issues. People accept all sorts of risks for other diseases that have much less morbidity– taking meds for life to lower cholesterol, for example. Your comment that buprenorphine or suboxone can be injected is correct. So can sugar water. So can saline solution. If a person has opioids in the bloodstream, buprenorphine precipitates withdrawal. The question about injecting I hear the most from addicts? They say ‘I keep reading that you can get high from injecting buprenorphine, but we could never figure out how to do that back when I was using. How do you get high from it?!’ All I say back is ‘you know, there are a lot of idiots out there.’

      I’ve worked in many areas of medicine, and there is nothing more emotionally satisfying in all of medicine, seeing people who are so beaten down by their addictions, who now feel completely normal, have absolutely no interest in opioids, and excel at home and at work. I often wish people could see how good they do, just for the sake of having less ignorance in the world…. but then I realize that my patients have their own private lives to live, and correcting ignorance is one of my hobbies– NOT my job, and not my duty, but just a hobby. So while it used to bother me, I no longer care if you have read this far, or if you’re still hanging onto your rigid, incorrect opinions. That is a shame though… you would think that anyone who knows two languages would keep reading until they get it right.

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      • December 5, 2018 at 8:05 am

        I would just like to say that I think that ALL ( or most ) doctors are uninformed about the LONG TERM side effects from buprenorphine use . I have been on this garbage for 10 years and guess what…. I was just diagnosed with CLL ( cancer ) . And doing my own research I have found many many people on chat rooms, blogs etc. that have CANCER after using bupe for many years, some getting tongue cancer from the STRIPS of the stuff and then having half their tongue’s removed. So I believe this drug is a carcinogen , like I said 10 years I have been on this and during those 10 years doing a lot of reading about bupe. and the true history of where and how it was invented . This junk should ONLY be used short term I would say max 2-3 weeks just like how some hospitals who have / had a buprenorphine program. this whole dr takes an 8 hour online class on buprenorphine is a joke, trust me I know I could go into great detail but I will leave it at this…. anyone on this long term GET OFF NOW . I have and currently sometimes day trade stocks and trust me people this ” wonder drug ” is ALL about the money, and a Dr that really cares would never let the patient determine the amout of bupe they are on.

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  • February 28, 2016 at 6:33 am

    If you think your right is the only true argumental right we have reached a false-positive in this coversation. I understand that through your witty comic relief kinda George Carlin point of view are trying to prove me wrong, paranoid and rigid in my opinions, yet I have actual proof about Suboxone doctor/buisnessman/dealer arangment in my current place of residing, and unfortunately using, as well. I even tried to blow the whistle on this particular case, and unfortunately for me as other people on this treatment… it did not came thru. If I could speak to you in any other way than comment/re-commenting I’d love to share my findings even just for the sake of your hobby, as it were.
    Godspeed.

    Reply
    • February 28, 2016 at 1:34 pm

      Understand that I can never tell the people who write with a smile, vs the people who are more even-tempered…but I am flattered by the Carlin reference. I don’t know where you live, and what the situation may be there. I also wouldn’t stake my own life, or even my credibility, on a bet that there are no crooked docs out there. But in the US, if you have true evidence that a doc receives money from pharma in return for prescribing, the place to go is the Board of Professional Conduct for your state, if in the US. Pharma can PAY FOR SERVICES– which they do all the time. But the pay isn’t like the rate that pro athletes get; it has to be at a rate similar to what other professionals receive for the same service.

      People are, of course, innocent until proven guilty– at least where I come from. So ‘proof’ has to be something beyond opinion or appearances or hunches. I DO realize that there will be/are practices that treat addiction with buprenorphine that are focused more on money than on patient care. But anyone who is angry about that should be doubly angry at all of the ‘treatment programs’ out there, on pretty coastlines, that have horrible outcomes. It is very easy to clean someone up for a couple months, and make him/her appear to be cured… and it irritates me how when those people invariably relapse, it is always the PATIENT who is blamed– never the treatment program….. which just keeps the money and moves on to the next desperate addict.

      I’m a big fan of whistle-blowers in general– so I hope you get someone’s attention eventually!

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  • March 9, 2016 at 6:03 pm

    Dr. Jung –

    I have been a fan of yours since starting treatment some 4 years ago and you are the one that I credit with my above average understanding of Suboxone/Buprenorphine treatment.

    Quick question as it relates to naloxone… I am having a kidney donation surgery in the coming months and I spoke to my prescribing Doctor (who is also an anesthesiologist) about what his recommendations would be in regards to my buprenorphine dose and the post operative pain management.

    He proceeded to tell me that since I take 16mg of buprenorphine daily, and NOT buprenorphine/naloxone, that I could stay on the medication throughout the surgery and post op and still receive proper analgesia with the narcotic meds. I did tell him that I was under the impression that I would need to stop the bupe several days before surgery, or else the pain meds would have no effect and I would be in misery. He stated that I would only have to stop taking the medication if I was taking the bupe/naloxone combo, but I’d be fine since there’s no naloxone in my meds.

    Let me just tell you that this scared me that an anesthesiologist was telling me this. All my research has shown me that in order to receive proper pain management, I would need to be off or on a very low dose of my bupe. And also, all of my research has shown me that no matter what, taking either bupe or bupe/naloxone, the naloxone would not get in my system enough for it to have an affect on anything.

    I’ll be honest and say that I’m not going to listen to him and stay on my 16mg during the surgery, as I’m absolutely positive that I will be hurting badly if I do.

    Do you have any recommendations for me? And am I even accurate in what I’m saying? I’m worried that since I’ve decided that I will be tapering and eventually be off the meds prior to surgery, that I will be in withdrawal and not feeling the best to go under the knife. My goal is to just be comfortable post op as any other patient would be.

    Thanks for taking the time to read this, and a big thank you for what you are doing for this community in terms of education and awareness. We appreciate you!

    Reply
    • March 9, 2016 at 8:07 pm

      Josh, you know more about Suboxone than the anesthesiologist. Feel free to email me at drj@fdlpsych.com , and we can discuss things further. You are correct; there is NO difference between ‘Suboxone’ and plain buprenorphine if you don’t inject the medication (and frankly, many people claim they are the same even when injecting them).

      You have two obstacles during surgery. First, you have a high opioid tolerance. Second, you are on a long-acting medication that blocks mu opioid receptors (i.e. buprenorphine). There are two ways to approach non-emergency surgery. The first way, the way described in an NIH monograph and and in a couple other places, is to stop the buprenorphine in advance of surgery. My problem with that approach is that it takes a couple weeks to get the buprenorphine out of your system, and you will enter surgery weak and dehydrated… plus, you will still have a high opioid tolerance and require higher than normal amounts of narcotic post-op. Your caretakers will likely assume that you only need normal amounts of narcotic, causing problems when you have pain in the middle of the night. Also, your tolerance to opioids will increase VERY quickly– so that by the time you leave the hospital you will be on 30 mg of oxycodone every 4 hours, or even more. You will need to ‘re-induce’ to go back on buprenorphine, i.e. go into withdrawal, and then start buprenorphine.

      My preference is described on my blog and forum, and only briefly mentioned in the NIH paper on treating acute pain in buprenorphine patients. I reduce the dose of buprenorphine (or Suboxone– it makes no difference) by 50%. Then I keep the person on that dose throughout surgery and post-op, and treat pain using oxycodone, usually 15-20 mg every 3-4 hours. For inpatients, I recommend going to the ICU and using PCA (patient-controlled analgesia) with fentanyl, setting the dose to a level about 3 times higher than ‘normal’. The problem is that everyone focuses on the dose– when instead they should focus on your respiratory rate and pain. Respiratory depression and analgesia are mediated by the same receptors– so if you are in severe pain, you are not going to stop breathing. But the ICU provides a margin of safety because they can have you on pulse oximetry.

      The advantages of my approach are that you don’t have to stop then re-induce buprenorphine. Patients typically say that they got good pain relief, but didn’t feel any ‘high’ from the narcotic. Your tolerance is anchored by the buprenorphine, so your tolerance won’t escalate as much as it would off buprenorphine. The transition back to buprenorphine or Suboxone is very easy; you just restart the buprenorphine when the agonist is discontinued. Finally, the people treating you will be constantly reminded that you are a buprenorphine patient. When you need pain relief, your use of buprenorphine will be right there in the ‘cardex’ that lists your meds. Anyone but a total idiot will know that you need more than the usual amount of narcotic, when you have pain in the middle of the night.

      The problem is that there ARE total idiots out there– and you may run into them in the middle of the night. But the issue will come up whether you are on or off buprenorphine– and at least ON buprenorphine, you don’t have to worry about being in withdrawal for a week or two before surgery.

      Good luck Josh!

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      • April 15, 2016 at 11:45 pm

        Dr. Junig,

        Based on my narrow scope of information, I believe that Suboxone helps opioid dependent people (I have a hard time with the word addict) because it negates the reward they would otherwise feel when using their preferred opiate.

        I was originally told that the naloxone was responsible for keeping the patient from experiencing any euphoria.

        After reading your blogs, I understand The science behind the drugs better and appreciate the education you provided. I do want to better understand, at what point, after stopping Suboxone or Subutex will that euphoria return, if ever?

        I feel that if able to experience a high, the deterrent for staying away from opiates will diminish exponentially and put the patient at riskof relapse…. Possibly resulting in a lifetime of buprenorphine prescriptions in some patients. Would you provide a brief statement on how that works?

        I get the impression that you’re passionate about what you do and it shows, thank you for the work and time you put into this.

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      • April 18, 2016 at 2:30 pm

        Thank you for keeping an open mind on all of this. Too often, even physicians, judges, or District Attorneys will think they understand how buprenorphine works– when in reality they have it completely wrong.

        You are correct that naloxone plays NO role in buprenorphine treatment except for (maybe) reducing the IV use of the combination product. Buprenorphine works by doing several things: 1. maintaining a relatively higher opioid tolerance so that any opioid use would require much higher doses of opioid; 2. blocking the receptor with very high affinity, again requiring a very high dose of opioid agonist (like heroin) to overcome that blockade; 3. providing a completely-constant level of opioid activation, which satiates the desire to use opioids without causing any opioid effect.

        The obvious question is ‘how does it satiate cravings, at the same time that complete tolerance develops?’ At least that is MY question. On one hand, I would say that maybe it isn’t the opioid activation that relieves cravings, but rather something more akin to what you are suggesting– a blocking effect on any opioid activity. But that is not the case– because the effects of buprenorphine are very different than the effects of naltrexone, a pure antagonist. Naltrexone does not directly relieve cravings, but rather supposedly works by the learned helpless model– i.e. the person knows that an opioid won’t work, so therefore loses interest in it. People who have been on both say that they are completely different experiences. On naltrexone the desire to use opioids and the fascination with opioids sticks around, often for a long time. Put an oxycodone tab on the table and the romantic pull is still there– even after the higher brain centers raise awareness that it won’t do anything if taken. But people on buprenorphine say, over and over, that their desire to use opioids just went away almost immediately. Sometimes I’ll have patients who still try using, and they will say ‘they used because it was there, and other people were using’, but they didn’t have a strong desire to do it’. Most of my patients– who tend to be over 30, and thoroughly sick of opioids by the time they see me— say that they lost the desire to use, almost immediately, on buprenorphine.

        Like most medical treatments, buprenorphine stops working when people stop taking it. I’ve lost almost all concern about patients taking buprenorphine for a lifetime– just as I have no concern about diabetics taking insulin for a lifetime, or people with heart valves taking blood thinners for a lifetime. I could go on for a long time with the comparisons– as with medicine, we almost always MANAGE illness, not CURE it. Somehow, a strange idea has developed surrounding one of the most lethal diseases affecting Americans: the idea that we cannot treat it with medication. THAT is the thought that people must challenge– and until that happens, many more will die. But for the individual who ‘gets’ the medical model– who understands that addiction is as deserving of chronic treatment as ANY illness–I recommend seeking treatment with buprenorphine. The side effects and risks are much lower than the risks for treatments of comparably-deadly illnesses. In fact, people on buprenorphine can lead a completely normal life— a far-better deal than someone with an organ transplant, on chemotherapy, on dialysis, etc… and frankly with fewer side effects than most high blood pressure medications.

        As for diversion– 20,000 people die from pain pill overdose each year in the US, but we still allow people to get pain treatment with those meds. Almost nobody dies from buprenorphine; 40 deaths per year have traces of the drug in the system, but in almost all cases, death was from on opioid agonist, and would have been prevented by MORE buprenorphine.

        I got off track– but as you see, I don’t think that blocking euphoria is the issue with buprenorphine. Buprenorphine is even under clinical trials as an antidepressant (by Alkermes).

        The battle right now is between the ‘lifetime medication’ folks– maybe that’s just me, but I hope not!– vs. the people who think that if we put addiction into remission with buprenorphine and counsel the heck out of them, the addiction will somehow disappear. That is a seductive thought– with absolutely no clinical evidence behind it. We have more and more evidence to the contrary, in fact. I think that some people like to see ‘addicts’ (I don’t like the word either) as people who ‘use because of this or that’, who would be fixed if ‘this or that’ was fixed. When I drop THAT assumption, I notice that the people who got addicted to opioids do not have any more ‘issues’ than anyone else. Everybody has SOME issue… and some people have MULTIPLE issues… but I have addicts and non-addicts from both groups.

        Reply
      • March 2, 2018 at 8:17 pm

        Wait wait wait. I’m confused on the surgery aspect. How can you take oxycodone while on suboxone or subutex and not experience withdrawal? I figured the buprenorphine would block the oxy and throw you into precipitated withdrawal? I was under the impression if you are on buprenorhine there is no way you could take oxy or another opioid while on it. That’s what everything I read says and why you need to be in withdrawal before starting so how does that work?
        Another question also I have been on oxy for 7 years and starting the subutex in two days. I’m at 700mg day. I know I know. Doc wants me to take 16mg first dose in morning and 8mg at night. Does that seem correct to you? This would be subutex. He also inaccurately said naloxone causes the precipitated withdrawal and I could take the subutex sooner than suboxone. That scared me he said that because it doesn’t seem true. I also take oxy for my anxiety and ocd and it has helped where dozens of ssris and mood stabilizers and Benzos have failed to help. Will
        I get therapeutic benefit from buphrenorhine in these areas like i do with oxy?

        Reply
  • September 4, 2016 at 4:42 am

    I’ve been on suboxone for 2 years, I’m currently down to 4mg per day but I’ve run into a cost issue because my insurance will not allow any more prior auth’s.

    So now, I have to pay cash for my suboxone.

    My problem is with the suboxone company/pharmaceutical itself as I’ve realized they’re far worse than the dealers I used to have to deal with on the street.

    Two months ago, my Dr. lowered me from 3/4 of an 8mg strip (6mg) to a 4mg strip which is where the problem arose.

    Getting the 8mg strips, at a dose of 6mg per day for four weeks, comes out to 21 8mg strips which I would then cut into appropriate daily portions.

    When Dr. Lowered me to 4mg strips he changed me to prescribing the 4mg strips for four weeks which is 28 strips…

    I am fine with the 4mg strips but when I had to pay cash for the strips I got the shock of my life when five different pharmacies told me that the 4mg strip and the 8mg strip cost exactly the same!

    Meaning, with the lower mg strip, I’m paying a lot more money for less mg’s… of course I just explained to my doctor that it would cost me half as much next time if he wrote the 8mg strips as opposed to the 4mg strips, because I would only need 14 strips instead of 28…

    I would just like everyone to know this and I don’t understand how they can get away with it. I am thinking of switching to Subutex to see if that saves more money.

    This has also motivated me to cut down sooner. I’ve found your blog very informative and thank you for your in depth explanations of everything involving suboxone and recovery. Thank you.

    Reply
    • September 4, 2016 at 5:50 pm

      Suboxone is an expensive medication, but the price is consistent with other brand-name meds. They ALL are ridiculously-expensive, given the low cost of the raw materials used for the production of non-biological medications (i.e. medications that consist of single molecules rather than those that are chains of amino acids or antibodies). Abilify, a useful psychiatric medication, costs almost $1000 per month for example.

      Many medications cost the same, or nearly the same, across the dosage spectrum– so if you can get prescribed a larger dose and divide it, by all means do it! Generic, plain buprenorphine is also inexpensive; in my area 60 of the 8 mg tabs cost $130, or about 2 bucks per pill– about a quarter of the cost of Suboxone. Some docs out there won’t prescribe plain buprenorphine because they believe patients will inject it. I recognize that a few idiots out there will inject pretty-much anything, including buprenorphine– so I watch patients on buprenorphine more closely, looking at their hands and arms at appointments and taking seriously any evidence of ‘diversion’.

      I hope your doc will help you with the price or insurance issue. Good luck!

      Reply
  • March 2, 2017 at 8:20 am

    Dr.you said that naloxone is destroyed once it hits the liver. So if you took suboxone on top of an opiate the naloxone would not cause the precipitated withdrawal right? Well I wasn’t on an normal opiate i was taking up to 10 grams a day of Tianeptine and I took suboxone before I felt any withdrawals from Tianeptine. Well needless to say I took suboxone right before bed and in 3 hours I woke up to full on withdrawals it was the worst feeling I have ever felt, I thought I was dying and called 911. When the paramedics showed up and I told them what I did they told me i was in precipitated withdrawals which are the worst withdrawals you will ever feel and they were right. I stayed in the bathtub for eight hours. So I hope you are right because I would hate for anybody (even my worst enemy’s) to feel what I felt. By the way sorry if this is hard to understand, i am a drug addicted not a English major

    Reply
    • March 2, 2017 at 10:45 am

      The naloxone in Suboxone is barely absorbed– about 3% gets into the circulation– and naloxone is metabolized very quickly and gone within 30 minutes or so. But you had precipitated withdrawal from the buprenorphine. That is a common misunderstanding; buprenorphine acts as an antagonist if opioid agonists are present and causes severe withdrawal symptoms, especially if the agonist is methadone (because methadone stays around so long).

      There is little to do if you have precipitated withdrawal other than waiting, and avoiding further use of agonists. The symptoms are severe, but never last very long– usually mostly gone by 24 hours. The best course of action is to continue buprenorphine at the prescribed schedule; additional doses will not make the precipitated withdrawal worse, but will help keep you from using agonists again. We discuss this issue at my forum— feel free to check it out.

      Reply
  • January 7, 2018 at 3:42 am

    Thank you Dr. Junig for educating the misinformed!

    Reply
  • October 16, 2018 at 6:24 pm

    Hi Dr.Junig
    Is one of the side affects of suboxone hot flashes & the sweets. They said the doctor said it was from the naloxone in suboxone and that they were switched to Subutex. I read your article about about suboxone and Subutex really just being the same and the the naloxone never reaches the blood stream because its pretty much gets destroyed would that mean sweating and hot flashes are a side effect of the bup.

    Reply
 

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