I’ll take a break from the book to post a question and answer with a reader:
My daughter’s doctor recently started prescribing her a pill called only ‘buprenorphine,’ instead of her usual Suboxone. Should I be concerned about the change?
You don’t mention the age of your daughter, but your question raises the issue of how involved should a parent be in the treatment of a child? Perhaps a more general issue is whether anyone should be closely involved in the treatment of someone with opioid dependence? After all, I frequently write that opioid addiction should be seen as ‘just another disease,’ and it is hard to make the case that people should share the details of their medical histories with others, at least after reaching adulthood.
But opioid dependence, while being a disease, does have some unique qualities—such as the effect of a worsening of the disease, i.e. relapse, on patients’ ability to make sound judgments. Over time, I typically want patients to become responsible for their own outcomes; adult children of too-involved parents sometimes seem to be stuck in a state of chronic defiance, where the addict seems to think that a relapse is a statement of independence or a reflection on the parents, rather than the addict’s own problem. But early on, it can be helpful to have someone monitor the addict’s behavior, and even control the buprenorphine. Just remember that only the addict him/herself can determine, in the long run, whether a buprenorphine program will work—or whether it will just be one more failed treatment method.
Suboxone and Subutex (generic or brand-name) are interchangeable for the most part— except generic buprenorphine is about half the price of brand-name Suboxone ($3 per tab vs. $6-$7). The main chemical difference is the naloxone in Suboxone, which is not present in Subutex or generic Subutex (aka buprenorphine HCL). Naloxone doesn’t cross mucous membranes; lipid soluble molecules like buprenorphine and fentanyl tend to pass through mucous membranes, and water soluble molecules like naloxone and morphine do not. When a person takes Suboxone properly the naloxone ends up being swallowed, absorbed from the intestine into the ‘portal vein,’ and then completely metabolized at the liver before getting into the systemic circulation by a process called ‘first pass metabolism.’ The features of buprenorphine that make it effective for treating opioid dependence (for example the ‘ceiling effect’) do NOT require naloxone. Naloxone is added to Suboxone for one reason—to prevent intravenous injection of dissolved Suboxone tablets. If Suboxone is dissolved and injected, the naloxone would enter the circulation, block opioid receptors, and cause an hour or two of withdrawal symptoms.
There is not a great amount of injecting of Suboxone going on out there, and so for most people, generic buprenorphine is fine. Some people who don’t completely metabolize the naloxone (because of genetic variants of liver enzymes, or perhaps because of taking cytochrome inhibitors like certain SSRIs) develop dysphoria for an hour or two after a dose of Suboxone, because the naloxone gets into their systemic circulation and causes withdrawal.
All patients who are pregnant are generally put on Subutex (or generic buprenorphine) because the low chance of injecting is not enough reason to expose the fetus to one more chemical.
I don’t know if your daughter is pregnant, but that would be one reason to take the generic. Or it may be a cost issue, or perhaps she sometimes felt sick after taking her dose of Suboxone. The theoretical risk from switching would be that she could then inject the buprenorphine, without the risk of withdrawal. If she DID inject, she would not get ‘high’ from doing so; the injected buprenorphine would have the same effects as when it is absorbed through the oral mucosa, only more quickly (i.e. zero effects, more quickly!). Even for people NOT tolerant to buprenorphine, injecting buprenorphine is not generally a great way to get high; the person develops a tolerance to buprenorphine very quickly, and within a day or two is ‘on’ buprenorphine going forward– incapable of feeling opioid effects because of mu receptor tolerance, and vulnerable to withdrawal if the buprenorphine is discontinued.
I’ll be back with another installment of the book in a few days. Thanks, as always, for reading; please share the site with other addicts and with those who love them.