Clarifying the Role of Suboxone
The role of Suboxone or Buprenorphine is mainly to treat Opioid Use Disorder. Suboxone is used in the treatment of withdrawal symptoms and cravings for opiates and opioids. Buprenorphine, which is the main active ingredient in Suboxone, can be used to treat Opioid Use Disorder in adults and children over the age of 15. There are times in which Suboxone will be used in pain management for patients, but there are important differences here. Suboxone is not approved by the U.S. Food and Drug Administration (FDA) to treat anything other than Opioid Use Disorder. Some physicians may write Suboxone as “off-label” treatment for pain management for individuals that have both pain management needs while having problems with addiction. The Buprenorphine single agent medication is the only one that has received FDA approval for pain management. It is also important to know that any medical facility providing Medications for Opioid Use Disorder (MOUD) is not to assist in pain management, those are two separate clinic specialties and need to be treated as such. If a person needs assistance with pain management they need to seek out a pain management facility for that treatment, not a treatment facility for Substance Use Disorder.
Safety and Precautions
Suboxone and pregnancy is a common concern with treatment facilities for Medications for Opioid Use Disorder. Before starting to discuss this topic there is some important data to learn. Opioid and opiate related deaths to women that are pregnant and the postpartum period 12 months after delivery is now one of the leading causes of pregnancy associated deaths. Between 2010 and 2017 the number of women with opioid related diagnosis at the time of delivery increased 131%. When looking at individuals suffering from Opioid Use Disorder while pregnant it is preferred that those individuals seek some form of Medication for Opioid Use Disorder. The reason for why this is preferred is that it greatly decreases the risk of overdose which will improve both the mother and child’s outcomes. Continued opioid and opiate usage during pregnancy has been linked with premature birth, poor fetal growth, birth defects, stillbirth, and neonatal abstinence syndrome.
Because of the dangers with continued opioid and/or opiate usage during pregnancy it is recommended for pregnant women to change to an assisted medication such as Suboxone, Buprenorphine, or Methadone. Of the medications it is recommended that Suboxone or Buprenorphine is used due to the lower risk profile when looking at neonatal opioid withdrawal syndrome when compared to Methadone. Suboxone is a brand of Buprenorphine which also contains Naloxone. In previous years people thought Naloxone to be dangerous for pregnant women. More recent research is proving Naloxone to not be dangerous for women during pregnancy or during breast feeding. Research has shown that if Naloxone does get into the breastmilk, it is likely the baby would not be able to absorb the Naloxone very well, if at all, from their stomach. Do understand that this is different than being treated with Naloxone, such as Narcan, for an overdose during pregnancy. What research was investigating was the consumption of Naloxone in the medication Suboxone. Please note that this is going off current literature and you should discuss any concerns and medications with your medical provider to assist you in making the best decision during a pregnancy and the year after. This blog is not intended to be used as medical advice, just informative of current literature.
There are some important interactions you should be aware of when taking Suboxone or Buprenorphine. The first and most concerning medication combination is with Benzodiazepines. Both Suboxone or stand along Buprenorphine and Benzodiazepines depress the central nervous system. When combined they can cause severe impairment, unconsciousness, comas, or respiratory failure, which could lead to a fatality. If an individual needs both medications it is possible to take them in a controlled environment with close monitoring by a medical provider but should be avoided if possible. There are no other currently known major medication interactions with Suboxone or Buprenorphine, but there are other substances and foods that can have negative affects if combined.
First, it is advised that anyone on Suboxone or Buprenorphine avoid grapefruit, grapefruit juice, and grapefruit-based products. There are many medications in which grapefruit and grapefruit-based products can have adverse side effects. Grapefruit is a strong CYP3A4 inhibitor, in which the metabolism of Buprenorphine (an active ingredient in Suboxone) is mediated by CYP3A4. Therefore, the consumption of grapefruit and grapefruit-based products could have prolonged and delayed effects of the Buprenorphine. Alcohol should be avoided as there can be severe interactions with Suboxone or Buprenorphine, including death. Alcohol is a depressant and when mixed with Suboxone (Buprenorphine) can increase the depression of the central nervous system, like that previously mentioned about Benzodiazepines. Some of the effects that can be caused from mixing Suboxone (Buprenorphine), and alcohol can include a deep sedation, slowed breathing, coma, low blood pressure, and possibly death.
Drug testing is a common practice of any treatment for substance use disorders, including that with Medications for Opioid Use Disorder (MOUD) with Suboxone and Buprenorphine. Many individuals in treatment view such testing as punitive and that the facility is trying to catch them. There are many beneficial reasons for drug testing, which is to assist in the safety of the patient and to prevent misuse and diversion of Suboxone or Buprenorphine. One reason drug testing is performed is to check for the usage of any other substances while in treatment. Such as that mentioned with alcohol and Benzodiazepines which can lead to fatal consequences. The usage of cocaine has been seen to lower the effectiveness of Buprenorphine and can lead to an eventual polysubstance addiction.
Drug testing is also used as confirmation that patients are taking their medication as prescribed. When medications are sold to other individuals that is called diversion of medication and causes multiple problems. First, anyone taking a medication not prescribed by a physician, especially a controlled substance such as that of Suboxone or Buprenorphine, is illegal. There are also considerable risks of taking medications without an evaluation by a medical provider such as the interactions listed previously with other substances, medications, and foods. Taking Suboxone which contains Naloxone while in active opioid or opiate addiction can cause a precipitated withdrawal for the individual. Another concern with the diversion of this medication is the problems it can place on those who are truly seeking recovery from Opioid Use Disorder from a needed medication.
The Drug Enforcement Administration (DEA) has an entire Diversion Control Division which is specifically tasked with detecting, preventing, and investigating the diversion of any controlled pharmaceutical medications from their lawful purpose into illicit drug trafficking. When individuals divert their controlled medications, it causes it to get harder for those seeking the medications for legitimate needs to obtain. This is a major concern with Suboxone and Buprenorphine and has caused both treatment facilities and pharmacies to enforce rules and regulations which make obtaining the medications much more difficult for everyone, just to assist with the DEA requirements on diversion. If diversion was to cease to exist, then this would open up more treatment options and the attainment of a lifesaving medication would be more readily available.
In more recent years it is common to find other substances mixed into illegal drugs that many users are unaware of. Some of these drugs are Fentanyl and Xylazine which are greatly increasing in being mixed into a variety of “street” drugs. Even some “street” pharmaceutical drugs such as Vicodin and Percocet are not as they appear and are just pressed Fentanyl, which in very low doses may appear to have the same effect on the user. The problem with the pressed Fentanyl is this is not a controlled production, and one pill could easily have a greatly increased amount of Fentanyl and cause an individual to overdose. Xylazine is almost never a desired substance of abuse as it is a non-opioid veterinary tranquilizer, now called tranq. Because it can produce intoxicating effects it has lately been seen mixed with Fentanyl to produce a more intense “high”. A large problem is that Xylazine is not Narcan reactant and is leading to an increase in unintentional fatal overdoses. Drug testing at treatment centers can assist in allowing patients who have relapses to understand the substances they digested, many of which are unknown to the individual. It does require a higher level of testing, such as the ones performed at Milestones Wellness Centers to be able to detect the exact substances in a person’s system. A simple urine test which is not sent for confirmatory results at a laboratory can give some basic information on substances used but will not give exact information.