Suboxone: Concerns Behind The Miracle

by Dr. Steven Scanlan, M.D.
One addiction may be traded for another as the FDA-approved opiate addiction treatment Suboxone is becoming one of the most prescribed medications in the country (#41 overall in sales in 2009 according to Called a “miracle drug” by some, Suboxone is estimated to be 25 to 40 times more potent than morphine.(1)
I am board-certified in psychiatry by the American Academy of Psychiatry and Neurology and board-certified in addiction medicine by the American Board of Addiction Medicine. I am the co-founder of Palm Beach Outpatient Detox (P.B.O.D.) in Boca Raton, Fla. I once was
addicted to opiates during my medical residency in anesthesiology and was detoxed with the help of Suboxone. Now I successfully detox my patients from opiates (e.g., morphine, OxyContin) using regulated amounts of Suboxone, and I also detox my patients from Suboxone addiction when that drug has been misused.
I have found that the optimal time to have someone on Suboxone is between 20 and 25 days, tapering down on the medication every few days. This makes the physical symptoms of detox very manageable, without causing the patient to become cross-addicted to Suboxone. I have found that Suboxone use for a longer period than this begins to cause a strong dependence on the medication.
Once a patient is stabilized with Suboxone and no longer getting high, he/she has to be convinced that recovery is possible. A detailed program is then created at the P.B.O.D. office, focused on abstinence and better coping techniques. P.B.O.D. prepares patients for the restlessness, irritability and discontent they will experience when they are off all narcotics, including Suboxone.
Suboxone detox makes the physical aspect of the disease manageable, but does not help with the emotional and spiritual consequences of addiction. Often patients are concerned about coming off Suboxone, but I educate them about how Suboxone is a tool to get them clean but not a suitable maintenance drug if a patient wants to get into recovery.
Suboxone is a powerful opiate-an anesthetic to emotional pain. It immediately alleviates anxiety and depression, and makes a person feel more emotionally stable. A lesser dose of Suboxone (2 mg a day) will block an estimated 80 percent of a person’s feelings, while higher doses can make a patient practically numb. Patients often say they feel great on Suboxone and since they are not getting high they want to continue on it. I tell them, “You are not dealing with your feelings because you are still not feeling-you are still numb. You need to start experiencing emotions to understand what you were trying to self-medicate in the first place. It’s time to live life on life’s terms.”

Duration of Use

When used in the short term, Suboxone is the best detox drug I have ever seen-it can immediately stabilize a patient’s life, and this can be done in an outpatient setting. When used long-term, though, it is the hardest medication I have ever dealt with in terms of detoxing a patient from it.
Suboxone does not work like natural opiates; it is created in a lab and interacts with the receptors in the brain unlike any other opiate. I speculate, based on treating hundreds of patients who have been on Suboxone maintenance, that when Suboxone is given long-term it causes abnormal adaptations to opiate receptors and other brain receptors. In my experience, long-term use can cause emotional deregulation, loss of libido, hair loss, and an abnormality in how the body regulates its response to stress.
Suboxone is a mixture of buprenorphine and naloxone. Buprenorphine is a powerful opiate, and naloxone is an opiate blocker used to resuscitate people in the ER from an opiate overdose. With no other opiates in the addict’s system in the last few days, he/she can either snort or intravenously shoot up Suboxone and become extremely high since it easily dissolves in water, making it easier to shoot up than heroin. The combination of there not being enough naloxone in Suboxone and the fact that Suboxone binds to the opiate receptor so strongly means that there is no built-in deterrent to keep a patient from abusing Suboxone. Dozens of my patients have discussed using Suboxone intravenously, and there are hundreds of reports about this on the Internet.
The misuse of Suboxone and the lack of attention to the problem are causing physicians untrained in addiction medicine to feed into overprescribing. Many do not understand the long-term ramifications of Suboxone addiction, and it also is a very lucrative business for the prescribing physician. Many doctors charge $200 to $300 monthly, per patient, for a 5-to-10 minute checkup to renew a Suboxone prescription.
Most places prescribing Suboxone maintenance do not offer any addiction treatment because the doctor is not trained in addiction medicine and because it is not time- or cost-effective to do so. Furthermore, the lucrative nature of Suboxone on a maintenance basis creates a disincentive to tapering the drug and its income-generating potential.
As a point of comparison I charge $2,000 for a detox from OxyContin or methadone, taking about three weeks. A detox from Suboxone dependence costs $5,000 because it takes four to five months, incorporating about 10 different medications to detox the patient successfully. The success rate for detox from Suboxone is much lower than that for detox from other opiates because patients tend to give up hope during the lengthy withdrawal process.

Dearth of Research

Most Suboxone studies follow post-detox patients for only a month and are often funded by the drug company that manufactures Suboxone. There are no long-term studies of Suboxone maintenance. I learned myself about the potential disadvantages of Suboxone maintenance from meeting people in my practice who have been on it for years.
I am concerned that the medical profession has allowed this situation to develop. I wish I knew how to fix this problem. I only know how to prevent it from happening to my patients in the first place or how to correct previous Suboxone treatment.
Only time will tell what role Suboxone will play in the field of addiction medicine. Will it one day be used only in the short term as a detox tool, or will it continue to be prescribed as a maintenance treatment? Supporters of maintenance treatment will state that the manageability of an addict’s life improves tremendously with Suboxone maintenance, and there is an abundance of research to back this up. Nonetheless, I believe that an individual on maintenance treatment is not experiencing the full range of emotions, good or bad. It is imperative, in the least, that all physicians prescribing this medication become more educated about Suboxone and the pros and cons of short-term and chronic use.
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