As the United States deals with the consequences of an epidemic of opioid overdoses that has ravaged neighborhoods and communities, doctors have been looking at various solutions to help people overcome their addictions to heroin and opioid-based prescription medicine. One example is Suboxone, hailed as a wonder drug for how it can help wean clients off their dependencies. But is it too good to be true? With an alarming number of people finding themselves hooked on their Suboxone, more and more questions are being asked about getting treatment for its abuse, including how long Suboxone withdrawal takes.
Suboxone: Buprenorphine, Naloxone, Opioids, and Full Agonists
Since its development, the name Suboxone has become very commonly used when talking about treating heroin and opioid addictions, but Suboxone itself refers to a combination of substances: buprenorphine and naloxone.
The Substance Abuse and Mental Health Services Administration explains that the brain has different types of opioid receptors, molecules on the surfaces of cells that bind to the chemical compounds in opioids, and through which the drugs can work their effects. When a person takes a hit of heroin, or an opioid prescription medication, and feels the painkilling, euphoric, and ultimately addictive feelings, it is the mu receptor that is being activated.
There are three different ways that opioids can react with receptors, which is important in understanding how Suboxone works and what influences the length of the withdrawal process. A drug that connects to, and activates, a receptor in the brain is called an agonist. A full agonist presents the biggest danger of abuse, as these drugs produce greater and greater effects, causing an addiction that is almost instantaneous.
Heroin, oxycodone, morphine, and methadone are examples of full agonist opioids.
Antagonists and Partial Agonists
On the other hand, antagonists also connect to opioid receptors but block them, instead of activating them. In the process of blocking the receptors, antagonists also prevent agonists from activating those receptors. Antagonists are like a key that fits in a lock, but do not actually open the door, and stop other keys from fitting into the lock. Naltrexone and naloxone are examples of opioid antagonists, which explain some of the effectiveness of Suboxone as a medically assisted form of opioid abuse treatment.
The last method of binding between opioids and receptors is for partial agonists. As the name suggests, partial agonists are part full agonists and part antagonists. Partial agonists connect to opioid receptors and activate them, but to a lesser degree than full agonists do. This means that partial agonists have a ceiling effect; that is, even if a person takes increasingly larger doses of a partial agonist, the painkilling and euphoric effects of the drug will eventually plateau. In fact, at higher doses, partial agonists resemble antagonists in that they connect to opioid receptors but do not fully activate them and prevent full agonists from working. This lowers the potential for abuse, creating withdrawal effects that are somewhat milder than those of full opioid agonists. Buprenorphine is a partial agonist, which is why it is a key component in using medication to treat opioid abuse.
Why is it important to understand the different ways opioids can bind with receptors in the brain, when talking about how long Suboxone withdrawal takes? Suboxone is a combination of buprenorphine (a partial agonist) and naloxone (an antagonist). Either one would have some effect in treating people who are addicted to full opioids, but they would be harmful if given in isolation. Buprenorphine can be administered to wean clients off a dependency on full agonists, but there is concern that this merely switches people to a lighter form of addiction, instead of helping them get fully clean. Similarly, naloxone’s chemical reaction of blocking opioid receptors is useful in undoing the effects of full agonists, but it has been known to trigger withdrawal effects in people who are chronically addicted to heroin or other full opioid agonists.
The Wonder Drug
Slate magazine writes that Suboxone is a “wonder drug” that the federal government should be aggressively promoting in the face of tens of thousands of people turning to heroin after getting hooked on their prescription medications. But many people in the medical community are hesitant to prescribe Suboxone, because of the risk it presents to vulnerable people and the popularity of the drug on the black market (what The New York Times calls “Addiction treatment with a dark side”).
Stories have emerged of people coming up with creative ways to bypass the abusive failsafes on Suboxone, such as dissolving the Suboxone strips in water to inject into the veins or crushing Suboxone tablets into powder to snort. “Addiction medication Suboxone now being abused,” writes the Courier Journal in Kentucky. NPR talks of how one man went on a Suboxone program to get off his painkiller addiction, but enjoyed the Suboxone so much that he resorted to buying pills from other patients. He described his behavior as that of an addict who was hooked on a legal substance.
Tapering vs. Cold Turkey Withdrawal
Suboxone’s reputation makes dependence on it a serious health issue, especially for people who have been made vulnerable as a result of prior opioid abuse. Writing in The Fix, Stacy Seikel, the chief medical officer at a treatment facility, warns that breaking an addiction to Suboxone is not an easy process; it takes a great amount of time and understanding. Too many people, she says, have attempted to get off Suboxone without sufficient medical observation, therapy, and social support, which impedes their recovery and puts them at risk for relapse.
If a person tapers off Suboxone, the process lasts 6-12 months. This is a prime time for therapy to keep reinforcing the recovery process (especially when it seems slow and frustrating) and to hold the client to a standard of accountability.
Cold turkey withdrawal, on the other hand, deprives the person of the chance to control the process of quitting Suboxone. There is no time to build a path to long-term recovery via therapy, and the painful and distressing symptoms of opioid withdrawal (e.g., muscle cramping, nausea and vomiting, anxiety and depression, wild mood swings, etc.) can be the catalyst for a relapse.
Some patients are so fearful of the prospect of a drawn-out withdrawal process (as with tapering) that they believe getting Suboxone withdrawal over and done with in one go is preferable to 6-12 months of gradual reduction. However, Seikel believes that without the support and trust of a doctor, quitting Suboxone becomes a superhuman effort – not impossible, but risky to the point of jeopardy. Cold turkey withdrawal robs the person of any control or comfort they would need to get through the process.
A Long-term Process
Seikel explains that for patients of hers who have been on a maintenance program of Suboxone, she tapers their intake of Suboxone every two weeks. Suboxone has a notably long half-life (37 hours), meaning that it has a long duration of action once taken (buprenorphine’s half-life can be as long as 42 hours). A two-week waiting period between dose reductions is an optimal period of time; for example, going from 8 mg to 6 mg of Suboxone will take the body almost a week to process the change. The first week allows the client to size up the impact of the new dose, communicating with the doctor about whether the change is manageable and how it impacts the other elements of their recovery (such as therapy, exercises, etc.). The information derived from this evaluation will help the doctor determine whether the dose reduction is working and whether future dose reductions can be plotted. This is not a level of care that can be performed if the client chooses to withdraw from their Suboxone via the cold turkey method.
It is only when the dosage is 4 mg or 2 mg that clients might report a notable difference in how they feel. Seikel writes that Suboxone binds to the opioid receptors in the brain so well, that doses over 4 mg can cover a “fairly high percentage of receptors.” A 2 mg dose, however, means that less than half the brain’s opioid receptors are covered, a change that would be significantly felt by the patient.
This provides a key opportunity for the doctor to work with the patient on understanding how the tapering process affects their feelings and recovery. It especially shows clients that the discomfort of transitioning to smaller doses passes fairly quickly, which should encourage them to persist with the tapering program that their doctor has formulated.
The Suboxone taper can be completed with doses that become incrementally more minute, as low as 1 mg or even 0.5 mg. This will help the client adjust to making the final transition completely away from Suboxone. Despite the process being much slower than cold turkey withdrawal, there should be no serious withdrawal symptoms when the tapering method is seen to its conclusion. A possible effect may be fatigue, but this passes in a matter of a few days and gives the client a clear head to focus on therapy and aftercare support.
From the First 72 Hours to Counseling
Seikel cautions that some clients will “absolutely” have to continue their Suboxone intake for a very long time, perhaps even indefinitely. Not everyone responds well to the tapering process, and this can be for any number of reasons (including previous drug use, current state of mental health, conduciveness of living environment to recovery, etc.).
The length and severity of Suboxone withdrawal is influenced by how long the client has been taking Suboxone (for some people, it could be a matter of years), any previous drugs they abused, any medications administered to ease the process (like benzodiazepines), how much Suboxone they last consumed, and how long ago that consumption went on. Furthermore, how the client withdraws – whether from tapering off or going cold turkey – can determine the length of the process. Suboxone tends to stay in the human body for 37 hours, so the rate at which Suboxone is discontinued will affect the length of withdrawal.
Due to all these factors, withdrawing from Suboxone can last for up to a whole month in cases of moderate Suboxone abuse, but could be the case for multiple months in the event of chronic Suboxone abuse or other factors that would complicate and lengthen the withdrawal process.
Symptoms are usually at their worst in the first 72 hours, manifesting in the physical ailments of muscle cramping, shivering, body aches, and nausea or vomiting. After that, the person will have to go through periods of insomnia uncontrollable mood swings.
By the second week, the physical symptoms would have subsided, but the psychological gauntlet will cause feelings of depression and anxiety (as well as cravings for more Suboxone), which mark the final set of symptoms. Even if this stage of treatment continues well beyond one month since the beginning of the Suboxone discontinuation process, the person will be in a good position to start counseling and therapy. Mental Health Daily writes that the 90-day point since the commencement of Suboxone tapering is usually a good time to evaluate the patient’s readiness for further treatment.
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