The Great Suboxone Debate
When it was first released in 2002, Suboxone was hailed as a major advance over methadone. But millions of scrips later, critics charge that the seductive opiate "cure" is causing its own epidemic of addiction.
Darlene Bryson (not her real name), 33, an office manager in the Texas oil industry, is in a tough spot. She’s been taking painkillers since 2008 for rheumatoid arthritis, a related rare skin condition, and chronic back pain. She was prescribed three 7.5 mg Vicodin per day. Eventually she found herself taking 10 or 12. “My Vicodin habit is not always for pain, if you get my drift,” she says drily. She especially liked Vicodin—the painkiller hydrocodone with acetaminophen—“because it slowed my mind down and made me a happy and pleasant person,” she says. When I heard this, I wondered to myself at how many other women have told me this story. It was also my own. Vicodin allowed me to “function.”
Recently, Darlene told her family doc she was hooked. She was shocked at his response to her honesty: he told her he could no longer treat her and booted her toward a Suboxone program. Darlene also sees a psychiatrist for a mood disorder. “He said that even if I got off Vicodin, I need to be on Suboxone to keep the cravings at bay,” she says. But she’s been reading about Suboxone on the Internet. “I’ve heard getting off [Suboxone] will be bad, too,” she says. “But if I get off Vicodin, why would I want to get back on another opiate?”
This is the question many addicts are asking about Suboxone. Should they take buprenorphine, or "bupe," long term mainly to avoid cravings—and the junkie lifestyle—or heal their bodies by detoxing and staying clean, which is harder and, in certain ways, riskier? Weighing the costs and benefits of each approach is a very personal, even existential, matter, and science can offer only limited advice, since there are no studies of long-term use of buprenorphine in former opiate addicts. We’re pretty much on our own.
Suboxone is the new kid on the poorly served addiction-treatment block. Its active ingredient, the semi-synthetic opiate buprenorphine, was FDA-approved for addiction detox and drug-replacement therapy in 2002. Among addicts and addiction specialists alike, opinions about “bupe” for maintenance therapy are sharply divided. Enthusiasts view long-term buprenorphine treatment as the best available solution not only to the life of crime, unemployment, poverty and dope-sickness led by many addicts, but also to the chronic depression that can follow detox. The opposing camp casts a cold eye on the Suboxone fervor, viewing its prolonged use as potentially devastating and the movement in support of bupe maintenance as a looming disaster in the addiction-treatment field.
There is, however, one thing both sides agree on: the little orange pill is a stellar detox aid. Until buprenorphine hit the scene eight years ago, most people who wanted to kick an addiction to heroin or prescription painkillers had only one option: methadone, a reddish liquid in a little cup dispensed at crowded, dismal special clinics because it is a Schedule 2 drug. But Suboxone (schedule 3) was hailed as the first in a new generation of addiction treatments that would revolutionize recovery, removing patients from detox and rehab centers, long viewed as sponsors of relapse, and into doctor’s offices and a pill-a-day routines. One of the primary advantages of buprenorphine for addiction-treatment is the fact that its partial-agonist quality prevents it from triggering respiratory depression—and thus overdose. In France, where the drug was in use for a decade prior to FDA approval, fatal overdoses of heroin and other opiates fell by 80%. The first bupe program for recovery from opiate addiction in the US, at Columbia University School of Medicine, recorded an 88% success rate at six months—success being no return to street drugs.
“Buprenorphine is the most important advance certainly in heroin and opiate treatment if not all addiction treatments in the last 30 years,'' Dr. Alan Leshner, a former director of the National Institutes of Drug Abuse, told The New York Times in 2004. Bupe works its detoxing magic in a more subtle, refined fashion that methadone. It takes the place of heroin and prescription opiates at the brain’s opiate receptors, binding tightly for days at a time and producing sufficient stimulation to cut withdrawal symptoms. Its binding power is stronger than almost any other opioid, so it kicks all other narcotics off the opiate receptors—they have no effect.
The reality of addiction, however, has so far stymied such revolutionary hopes. For one thing, bupe’s capacity to soothe the devious cravings that pursue addicts long after detox is limited, at best. Switching from one opiate (heroin, methadone) to another (bupe) does not “heal” the neurological aspect of addiction, which is characterized in part by the phenomenon of tolerance: as long as exogenous opiods are taken, the body decreases its production of endorphins and increases the number of receptors.
In the US, buprenorphine is usually prescribed in 2 mg and 8 mg tablets. Two generics are on the market: Subutex is bupe-only, and Suboxone contains four parts bupe to one part naloxone, an opioid antagonist designed to prevent addicts from abusing the drug. If crushed and shot or snorted, the manufacturer says, the naloxone will put the user into withdrawal.
“That’s just dishonest advertising,” says Dr. Steven Scanlan, a psychiatrist and addiction specialist. Scanlan is the medical director of Palm Beach Outpatient Detox, in the heart of Florida pill-mill country—where, he says, more than two-thirds of the nation’s oxycodone or “Oxy” scrips are written. “The naloxone doesn’t prevent you from shooting it. I’ve talked to dozens of people who have shot or snorted it.”
Scanlan says he has detoxed thousands of addicts from all sorts of prescription drugs, including benzodiazepines, like Valium and Xanax, and hypnotics like Ambien—and also alcohol. But his specialty is detoxing opiate addicts, and he uses Subutex for the scads of Oxy fiends who come to him in desperation, many with levels of 300 to 600 mg coursing through their bloodstream. “Buprenorphine is the most amazing detox tool I’ve ever seen,” he says flatly.