As the opioid epidemic continues to rage on, killing 115 Americans each day on average, one of the most effective treatments for this devastating addiction is also one of the most controversial.
Subutex vs. Suboxone: Which Is Better & How Do They Shape Our Idea Of Addiction?
Buprenorphine, marketed as Subutex and Suboxone, has helped countless opioid addicts in a variety of ways. It can eliminate the overwhelming cravings and withdrawals that come with this class of drug; it helps reduce the chances of a deadly relapse; and for many, it’s a way to finally start feeling normal again. And still, despite the enormous benefits that this medication can provide, some argue that taking Suboxone or Subutex is simply trading one addiction out for another. Complete abstinence, they claim, is the only acceptable means of recovery. But as this debate continues to rage on, first thing’s first: what’s the difference between these two medications anyway? How do they work in the body to help give opioid users a new lease on life? How effective are they compared to the alternatives? And finally, when it comes down to Subutex versus Suboxone, which is the better option? Let’s have a look.
A Quick Update on the Opioid Epidemic
In order to really understand how crucial it is to find and make use of effective opioid addiction treatments, it’s important to recognize just how bad the problem has actually gotten. So, here’s a quick refresher. According to the National Institute on Drug Abuse and the CDC:
- From 1999 to 2016, more than 350,000 people died from an overdose involving any opioid.
- Around 66% of the more than 63,600 drug overdose deaths in 2016 involved an opioid.
- In 2016, the number of overdose deaths involving opioids was 5 times higher than in 19999.
- Roughly 21 to 29% of patients prescribed opioids for chronic pain misuse them.
- About 80% of people who use heroin first misused prescription opioids.
- Opioid overdoses increased 30% from July 2016 through September 2017 in 52 areas in 45 states.
- Opioid overdoses in large cities increased by 54% in 16 states.
Given just how bad things have gotten, it isn’t any wonder that there are nearly hundreds of lawsuits filed against opioid manufacturers. In fact, as of May 2018, 22 states along with Puerto Rico and numerous cities are all actively suing drug companies like Purdue Pharma and Endo Pharmaceuticals for violating consumer protection laws.
What Makes Opioids So Dangerous?
As you can see, the health crisis behind opioid misuse is only getting worse. And despite the numerous laws, sanctions, and guidelines that have been created to help curb the problem, overdose rates still continue to rise. So the question is, what is it about this kind of drug in particular that makes it so dangerous? It comes down to three factors. Opioids are highly addictive, hard to quit, and especially deadly.
- Highly Addictive – A quick, intense high along with a rapidly-building tolerance are two major characteristics to blame for the addiction potential of opioids. The more powerful the high is, the more your brain becomes hardwired to crave it. And as you continue to use them, you start to need higher doses in order to get the same high.
Eventually, an opioid user will become so physically dependent on these drugs that they won’t be able to feel pleasure from anything else in their life – friends and family, hobbies, even food and sex. On top of that, they’ll end up needing to take massive amounts of the drug just to feel pleasure at all.
- Hard to Quit – It’s widely recognized that once you get addicted opioids like heroin and OxyContin, it can be incredibly hard to quit. Part of that has to do with the intense symptoms of withdrawal.
Many people find it difficult, if not impossible, to push through the discomfort of this process on their own. And as a result, they end up turning back to drugs just to start feeling normal again. Some studies have even found that the relapse rate for drugs like heroin is as high as 91%!
- Especially Deadly – There were more than 630,000 overdose deaths from all drugs from 1999 to 2016. During that time, opioids were responsible for 350,000 of those deaths. And as the years go on, drugs like heroin and Fentanyl are becoming increasingly responsible for more deaths than every other drug combined.
The danger is twofold. First, opioids are exceptionally effective at stopping respiration – the main cause of death during an overdose. Second, street opioids like heroin are regularly cut with both harmful fillers and other drugs that are particularly potent. Even one hit off of a bad batch is enough to substantially increase the risk of a deadly opioid overdose.
What Does Opioid Withdrawal Look Like?
Opioids are notorious for having some of the most unbearable withdrawals. To get a better idea of just what kind of physical and mental torture’s involved, take a look at some of the most common symptoms as reported by Mental Health Daily.
- Dilated pupils
- Heart palpitations
- High blood pressure
- Hot flashes
- Muscle aches
- Runny nose
- Watery eyes
- Concentration problems
- Crying spells
- Memory problems
- Panic attacks
- Suicidal thoughts
Added to this long list of symptoms, opioid users may also go through what’s known as Post-Acute Withdrawal Syndrome or PAWS. According to UCLA’s Semel Institute for Neuroscience and Human Behavior, PAWS “refers to a set of impairments that can persist for weeks or months after abstaining from a substance of abuse.” Some of these impairments include:
- Difficulty with cognitive tasks, such as learning, problem-solving, or memory recall
- Feelings of anxiety or panic
- Depressed mood
- Obsessive-compulsive behaviors
- Difficulty maintaining social relationships
- Craving originally abused substances
- Apathy or pessimism
- Disturbances in sleep patterns
- Increased sensitivity to stress
And with opioid abusers, the risk of going through PAWS is especially high. Some estimates actually put the risk of developing at least some degree of the condition for opioid users at an astounding 90% according to Semel. Recovering addicts report feeling depressed, anxious, and ultimately uncomfortable in their own skin. And it’s this sense of something being just “off” that typically drives so many opioid users back to doping again – even after weeks or months of being sober. It’s just one more reason why getting clean from opioids is just that much more brutal.
Let’s Get Into Buprenorphine: How Does It Help?
Alright, now that we’ve covered why it’s both critical and difficult to recover from an opioid addiction, let’s take a look at how buprenorphine (Subutex and Suboxone) can help. The reason why addicts go through withdrawals when getting clean is that the brain and body have been fundamentally altered over the course of an addiction. They’ve become physically dependent on having opioids in the bloodstream in order to function normally. Without enough of these opioids to stimulate certain receptors in the body, the system starts going haywire – the results of which are incredibly uncomfortable symptoms of withdrawal. If, however, you stimulate these receptors, the symptoms of withdrawal go away. That’s where Opioid Replacement Therapies come in. These treatment methods (also called ORTs) use unique drugs that interact with the special receptors to reduce the intensity of withdrawals, but limit the stimulation so as not to produce a “high.”
There are three ORTs that are currently approved by the FDA to treat opioid dependency:
And while methadone has been used for decades as the main ORT for clinics around the country, buprenorphine is overthrowing this drug as the “gold standard” for Opioid Replacement Therapies.
Both methadone and buprenorphine are what’s known as an opioid agonist, meaning it stimulates the opioid receptors in the body while blocking other agonists from stimulating them. Naltrexone, another powerful opioid addiction recovery drug, is an opioid antagonist, meaning it simply blocks other drugs from interacting with these same receptors. As such, naltrexone is a great option for opioid addicts in the later stages of recovery, but it won’t eliminate the painful withdrawals like buprenorphine and methadone.
What’s the Difference Between Buprenorphine & Methadone?
Methadone, which was first synthesized in the late 1930s, is largely being replaced by the safer, more versatile buprenorphine during Opioid Replacement Therapy. But what makes these two drugs different anyway? The biggest difference between the two is the degree to which each stimulates opioid receptors. Methadone, for example, is a full opioid agonist. That means that methadone molecules tend to bind tightly and fully to the receptors, causing maximum stimulation. Other full opioid agonists include heroin, fentanyl, codeine, morphine, hydrocodone, and oxycodone Buprenorphine, on the other hand, is a partial opioid agonist, meaning it only partially fits into and activates the receptor. Other partial opioid agonists include butorphanol and tramadol. It helps to imagine your receptors as Phillips head screws (+). Full opioid agonists like methadone can be thought of as a Phillips screwdriver (+). It fits snuggly into the slot and as a result, is perfect for tightening (or activating) this particular kind of screw. Partial opioid agonists like buprenorphine, though, are more of a flathead (-). Now, they can fit into the screw and tighten it to a certain degree. But since they aren’t a perfect match, it’s much harder to tighten it as much as if you had a Phillips. Buprenorphine drugs like Subutex and Suboxone, then, don’t activate opioid receptors nearly as much as methadone. And there are a variety of benefits that come from this quality in particular.
Why Is Buprenorphine Becoming More Popular Than Methadone?
The main factor here is a lower likelihood of abuse. As a partial agonist, drugs like Suboxone and Subutex don’t hold nearly as much abuse potential as methadone simply because it’s harder to get high off of them. If someone, for example, were to get their hands on a double dose of methadone, they could take both and end up achieving a euphoric high as a result. With buprenorphine, though, an individual can only take so much before they run into what’s called “the ceiling effect.” Once they hit that ceiling effect, no matter how much buprenorphine they take, they still won’t feel any increase in the drug’s effects. It’s like a natural abuse deterrent built right into the drug itself! As a result, doctors can even prescribe Suboxone and Subutex to patients for use at home rather than recovering addicts having to take the medication at a designated facility like with methadone. Buprenorphine also has what’s known as an especially high “affinity” for opioid receptor sites. This quality is basically a measure of how attracted a drug is to the receptor. And if a medication has a higher affinity than another drug, then that medication can actually stop a drug like heroin from activating that receptor. Consequently, taking heroin while using buprenorphine (called “chipping”) will often lead to a complete block of the high associated with the drug. All of this – the lower degree of activation, the ceiling effect, and the blocking of other opioids – adds up to an addiction recovery drug that’s safer, more easily administered, and more effective than nearly any other treatment option.
Can You Still Abuse Buprenorphine?
As opioids themselves, both Suboxone and Subutex do carry at least some risk of abuse even though they are only partial agonists. The main threat, however, has to do with drug users who haven’t built up an opioid tolerance. To explain, buprenorphine only activates opioid receptors to a certain degree as we’ve just seen. In most cases, patients who have been prescribed buprenorphine have an especially high tolerance due to weeks, months, or even years of substance abuse. As a result, the stimulation that buprenorphine provides won’t usually be enough actually to produce a high. Users who have not built up that same tolerance, on the other hand, may experience some degree of euphoria and pain relief after taking the same dosage. It probably won’t be as intense as other opioids. But still, this can lead to a pattern of abuse. Added to that, mixing Suboxone or Subutex with other types of drugs can cause overlapping effects. Taking these drugs and drinking alcohol, for example, may boost their effects and lead to increased drowsiness, a higher risk of respiratory depression, and other serious problems. And finally, buprenorphine can also be injected rather than taken as prescribed to cause a more intense high. This can bypass the body’s natural filters and lead to a high more similar to street drugs like heroin. In the end, the answer is yes. You can still abuse buprenorphine. But it’s significantly harder to do than with other drugs.
What’s the Difference Between Subutex & Suboxone?
Both drugs are used to treat opioid dependency. Both are made from buprenorphine. And both were approved by the FDA in 2002. So, what sets them apart? The main difference is that Subutex’s active ingredient is only buprenorphine. Suboxone, however, has one extra special chemical touch – the presence of naloxone. You see, Subutex (which actually hit the market earlier than Suboxone) was having enormous problems with abuse potential. Users were either selling their prescription on the street to people with a lower tolerance, or they were melting down the pills and shooting them up to get an intense burst of a high. And while the drug certainly helped reduce withdrawals that recovering opioid addicts were going through, the benefits were being overshadowed by the medication’s abuse potential. Suboxone manufacturers tackled the abuse problem by including the unique compound naloxone in their product. Naloxone, technically classified as an inverse opioid agonist, causes the rapid removal of any other drugs bound to the opioid receptor. As a result, anyone who has opioids in their blood and then takes naloxone will enter a state of precipitated withdrawal – basically immediately experiencing all the unbearable effects of opioid withdrawal. And the discomfort is so intense that no one in their right mind would want to go through it willingly. Using Suboxone illicitly, then, will not only not cause a high, but it will also instantly bring on one of the most physically and mentally excruciating experiences possible. And best of all, Suboxone only causes this reaction when the drug is injected, not swallowed – meaning if it’s used properly, there’s zero risk of this reaction. It’s a powerful abuse deterrent that cements Suboxone as the superior Opioid Replacement Therapy.
Is It Possible to Become Addicted to These Drugs?
Technically speaking, yes. Both drugs are classified as opioids, and both can be used to create a high. As a result, both can lead to compulsive addictive behaviors that can have a serious negative effect on your life. However, it’s important to recognize the difference between physical dependence and addiction. Physical dependence is characterized by tolerance and the presence of withdrawal symptoms. When you’ve become physically dependent, your body has grown so used to the drug that it can’t function normally without it. Addiction, on the other hand, is defined by NIDA as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” Addiction, then, is more about a pattern of behavior rather than how your body reacts to the drug. When using Subutex or Suboxone, an individual may become physically dependent on it. They may start to feel sick if they don’t take it. And they may have to start taking more and more to avoid those symptoms. But in most cases, recovering addicts won’t feel the same compulsive need to use these drugs despite negative consequences, especially when taken properly. And once again, as NIDA puts it, “Thus physical dependence in and of itself does not constitute addiction, but it often accompanies addiction.”
Can You Stay on Suboxone or Subutex Forever?
Most addiction professionals agree that both Suboxone and Subutex should only be used in the short-term. For some individuals with especially severe addictions, physicians may recommend going on a buprenorphine maintenance plan where the drug is taken throughout addiction rehab as well as over the course of months or even years. But for the majority of addicts, both Subutex and Suboxone should be weaned off of as soon as possible. The longer you take this drug, the more your body will become physically dependent on it. And that can mean coming off of the drug may end up being far more painful than it has to be. Essentially, buprenorphine is a fantastic way of making it easier to get through withdrawals and help you feel normal again while you’re going through recovery. But as helpful as it is, you just can’t keep taking Suboxone forever.
What’s Wrong With the Concept of “Trading One Addiction For Another?”
Herein lies the main controversy surrounding these drugs, as well as Opioid Replacement Therapies in general. Many people are under the false impression that taking one opioid to stave off the withdrawals and cravings caused by another is missing the point of recovery. They think that doing so is simply trading one addiction for another. As we’ve seen, though, just because a recovering addict starts taking Suboxone or Subutex – and even if they develop a physical dependence – it doesn’t mean that they’re actually addicted. But more importantly is the fact that this type of thinking – the complete abstinence approach – is not only less effective, but it’s also actually far more dangerous. Studies have shown that Medication Assisted Treatments like taking Subutex and Suboxone:
- Decrease opioid use, opioid-related overdose deaths, criminal activity, and infectious disease transmission.
- Increase social functioning and retention in treatment.
- Improve infant outcomes for opioid-dependent pregnant women.
In fact, the World Health Organization even characterizes these drugs as “essential medicines.” Since ORTs are clearly more effective and safer, why are some people so vehemently opposed to them? Part of the problem has to do with the fact that many people are still under the impression that addiction is the result of some moral failing – a flaw in a person’s character or willpower. They often think that if the addict was just a little more responsible, a little stronger, or a little less selfish, they could overcome their drug habit. But what they fail to realize is that addiction is actually a disease – one that manifests as physical changes in the brain and body. And these changes make it near impossible to stop using without professional help. As a result, addicts need to be treated rather than punished. And when it comes to treatments that can make recovery all the more likely, drugs like Suboxone and Subutex are at the top of the list.
Buprenorphine – A Promising Weapon in the Fight Against Addiction
In the matter of Suboxone vs. Subutex: which is better, the winner is clear. Suboxone has the same withdrawal relieving power of buprenorphine and has much less potential for abuse than Subutex thanks to the addition of naloxone. And while recognizing the more useful of these two drugs is one thing, the more important step is to take a closer look at how we think about addiction. Once we recognize that this devastating condition – which only continues to get worse – is an actual disease and begin treating it as such, we can help people recover much more effectively. And hopefully, give them some hope of returning to a normal life as well. Have you taken Suboxone, Subutex, or any other Opioid Replacement Therapy? What was your experience like? Did they help you recover from your opioid addiction? Let us know in the comments below and as always, if you need addiction treatment help or have any questions at all, don’t hesitate to contact us today.
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