How Do I know if Suboxone Is Right for Me? The Best Opioid Addiction Treatments For You or Your Loved One

January 15, 2021

J.D. is a 42 y/o male who has struggled with addiction to percocets (an opioid prescribed by his doctor) after a back injury in 2011.  While 2011-2014 were a “dark” time for him when he found himself craving opioids, increasing the amount he was taking, going to the street for more, losing his job, and creating significant stress at home, J.D. has now been in recovery for over six years.

J.D. explains, “There was one point, I realized I could not keep living this lifestyle. I was ashamed of the stress I put my family through.  So, I enrolled in a Suboxone program, I got a therapist, and I got a sponsor.  That was six years ago, and today, I still take my Suboxone every day, I talk to my Suboxone doctor on the phone every month,  I see my therapist every 2 weeks, and I call my sponsor daily.  All these things keep me on track and I’ve been back at my job--now as head restaurant manager--for 4 years, I’m saving up money to send my kids to college, and my family trusts me again.”

J.D. has clearly invested a lot of effort into his recovery and is reaping the benefits. For patients similarly struggling with addiction to opioids (like oxycodone, dilaudid, percocet, vicodin, heroin, fentanyl), finding themselves in a “dark” place, and wanting to get help, what are the treatment options?  And, how do you decide which is best for you?

Medications for Addiction Treatment (MAT)

Our understanding of addiction has markedly evolved over the past few decades.  While it used to be thought that addiction is “moral” disease and must be overcome by sheer “will,” science has taught us that addiction is a life-long, chronic brain disease and responds best to medications for addiction treatment (MAT).

MAT includes three medications- methadone, buprenorphine/naloxone (Suboxone), and naltrexone (AKA vivitrol). They all suppress opioid cravings. Buprenorphine/naloxone (Suboxone) and methadone (but not naloxone) prevent withdrawal symptoms.  And, they all prevent you from overdosing on opioids.  When taken as prescribed, they make a person feel normal and able to engage in daily activities.

The scientific evidence supporting MAT is clear. Patients with opioid addiction NOT on MAT are six times more likely to die of an overdose compared to someone who does not have an addiction (the general population).Those who take MAT are more than 3 times less likely to die from an opioid overdose, so these medications are essentially reducing mortality rates 3-fold.. On the whole, once patients taking these medications regularly, methadone, buprenorphine, and naltrexone all have similar rates of effectiveness: approximately 50% will maintain their recovery for at least 1 year.

While the transition from opioids to buprenorphine and methadone is brief and relatively easy, the transition to naltrexone can prove much more difficult because a person has to be OFF opioids for 7-10 day before starting naltrexone, which can be difficult for patients who are used to using opiates every day. These patients often require comfort medications to make the transition, though once they make the transition they have similar rates of effectiveness as patients taking buprenorphine/naloxone (Suboxone) and methadone. Click here to learn about the evidence supporting MAT (See: Misconception #5).

But, which medication is best?

Though your doctor might recommend one option over another, the choice of which medication to take is really a personal decision.

So, what’s the difference?

Here is a table that explains:

Buprenorphine (aka Suboxone) Methadone Naltrexone (aka Vivitrol)
How it works in the brain Partially activates opioid receptors Fully activates opioid receptors Blocks opioid receptors
How it helps with addiction to opioids Prevents cravings, withdrawals, and overdose Prevents cravings, withdrawals, and overdose Prevents cravings and overdose
Safety profile Has ceiling effect; VERY difficult to overdose
Interacts with few other medications
No ceiling effect, risk of overdose if too much is taken
Multiple drug-drug interactions
Must monitor heart rhythm with regular testing
VERY safe; it works against opioids so you cannot overdose on it
Do NOT take with opioids; the opioids will be ineffective
Typical dose & formulation Suboxone (8 mg buprenorphine- 2 mg naloxone); most patients stabilize at 12-16 mg buprenorphine/ day (1.5-2 Suboxone tabs or films/day); can take up to 24 mg/day
taken sublingually: dissolves under tongue in ~15 minutes
60-120 mg/ day
taken orally: in liquid, powder and diskettes formulations
380 mg dose injected monthly into the buttocks muscle, continuously released throughout the month;
Some patients report they begin to have cravings during the fourth week after injection; providers can augment with oral naltrexone dosed 50-100 mg/day during this last week
Time to reach maintenance (stable) dose Usually 1-2 days Doses start at 20 mg day, can increase dose every 2-5 days, takes ~ 2 weeks to reach maintenance dose Two hours after injection
Where medication is obtained & taken Patients get a prescription from a DEA-waivered physician in ANY treatment setting (like other prescriptions) and can take the medicine in their home Patients must travel to a specialty clinics (Opioid Treatment Programs- aka “methadone clinics”) which are highly regulated by federal & state accreditation and take the medicine under supervision Does not require special license; can be provided in outpatient and specialty clinics
Amount of Structure Usually requires weekly appointments, patients doing well may be spaced-out to bi-weekly or monthly appointments Usually requires daily visits; after months-years in recovery, patients meeting specific federal criteria can earn “take homes” and not have to come in as often No associated regular structure; at minimum, patient receives monthly injection and programs decide how often the patient is required to attend appointments
Does it help with pain? Yes, Suboxone is considered as strong as “taking a Vicodin” for pain relief. But that is not what it is being used for. Patients taking Suboxone to treat addiction may need additional non-opioid pain medications. Yes, methadone is a strong pain reliever. But that is not what it is being used for. Patients taking methadone to treat addiction may need additional non-opioid pain medications. No, as an opioid antagonist, naltrexone blocks (rather than stimulates) opioid receptors
Patients taking naltrexone to treat addiction may need additional non-opioid pain medications.
Safe in pregnancy Yes- considered first line treatment Yes- considered first line treatment We do not know as there is not enough evidence as of yet.
Other pearls Suboxone also binds to other receptors that boost your mood! So it works as a mild antidepressant. Naltrexone is also used for patients with alcohol use disorder (AUD), so it is a good choice for patients struggling with opioids and alcohol.
How has COVID-19 changed things Patients can start Suboxone without an in-person visit While each program is different (and must seek state approval), patients are getting more “take homes” but they still CANNOT start methadone without an in-person visit Patients need an in-person appointment for each monthly injection.


What about mental health?  Do I need to see a therapist also?

While the science is VERY clear that medication therapy works incredibly well for treating opioid addiction, the science behind mental health therapy is less clear: some scientific studies suggest no added benefit, while other studies suggest patients do better when they get mental health support. (2)

Since many patients with addiction to opioids also struggle with depression, anxiety, post-traumatic stress disorder (PTSD),  many have histories of trauma (verbal, physical, and sexual abuse), and most have daily life stressors, learning how to cope in healthy ways-- that don’t involve drugs-- is an important part of recovery that therapy can help with.

As Dr. Brian Clear, Chief Medical Officer (CMO) of Bicycle Health, a telehealth company that provides buprenorphine to patients with opioid addictions explains,  “Because addiction is really a bio-psycho-social disease, meaning it is a chronic medical disease with mental health and environmental components, it really requires a comprehensive approach to treatment that involves both medications and behavioral support.”

So, what does mental health support look like?

Mental health support can take many forms:

First, patients can receive individual, group-based, and family therapy with a psychologist, social worker, or addiction-trained nurse or counselor. These professionals often utilize several approaches to help patients.

1) Motivational Interviewing (MI) (3,4,5)

When patients are “on the fence” about whether or not they want to address their addiction, MI helps motivate them to engage in recovery efforts and formulate next steps to treatment. 

 2) Cognitive Behavioral Therapy (CBT) (6,7,8)

A counseling style that helps patients identify harmful thoughts, assess whether they are an accurate depiction of reality, and, if they are not, employ strategies to challenge and overcome them.

3) Community Reinforcement Approach (CRA) (9,10,11)

A therapeutic approach that helps patients identify goals around “people, places and things” to minimize triggers and risk factors for drug use and maximize supportive and protective factors for drug use.

4) Contingency Management (CM) (12)

An approach that rewards patients for good behaviors, further incentivizing them to invest in their recovery.  For example, patients attending a buprenorphine/naloxone (Suboxone) group who are doing well in recovery might get longer duration of prescriptions, may get “spaced out”-- ie required to see their doctor less often, and might even get rewards for having toxicology tests that show no illicit substances (ex: entered into a lottery for a prize).

Patients can also utilize peer support-- meaning getting support from others who have struggled with addiction and have been doing well in recovery for awhile.  These include:

  1. Recovery coaches- have specialized training to support their peers.  More information here.  
  2. Sponsors- usually more informal and found within 12-step (AA/NA) programs. More info here.

Peer supports often call patients daily to check in on them and hear about their lives. They can also help them navigate “the system” to seek further treatment options, like detox programs, inpatient hospitalizations, intensive outpatient, residential, methadone, or buprenorphine/naloxone (Suboxone) programs.

Going to Twelve-step meetings like AA/NA offers patients the opportunity to get support from a group of people who have had similar life experiences and struggles. Twelve-step programs utilize a spirituality, fellowship, and a “higher power approach as patients engage sequentially in the twelve steps of the “Big Book.”  Many patients like this spirituality focus, while others may be turned off by it.  Smart Recovery also offers a group-based supportive approach, but it is less spirituality-focused and instead employs cognitive behavioral therapy strategies-- ie teaching patients to change the way they think about things, leading to changing the way they behave.

To learn more about AA/NA: https://www.aa.org; https://www.na.org 

To learn more about Smart Recovery: https://www.smartrecovery.org

Other groups: It is also important that your loved ones understand what addiction is so they can best support you and take care of themselves. There are several groups that support family members of loved ones struggling with addiction. To learn more, go here.

What about format?

The COVID-19 era has ushered in a new model of care-- telehealth-- that allows patients to receive treatment via telephone calls or video calls without having to come to a clinic.

Many patients find this format to be a safe way to take care of themselves during the COVID-19 pandemic.  It also provides the convenience of not having to travel, and it allows patients to be treated from “the comfort of their own home.”  Many programs also provide toxicology testing that can be done without going to a lab. For example, at Bicycle Health, patients are able to do home urine toxicology tests, take pictures of the results, and send it to their providers to review and load into their charts.

For buprenorphine and naloxone, since these medications are usually prescribed in an outpatient clinic, federal and state regulations have allowed telehealth to occur without any in-person visits.  For methadone, which usually is prescribed daily at an opioid treatment program (also known as a methadone clinic), regulations are more state dependent--- with most allowing for some telehealth visits in conjunction with in-person visits, though all still require an initial in-person visit.

However, it is also important to recognize that some patients may reap benefit from in-person treatment.  The accountability associated with showing up for an in-person visit, and the socialization that occurs with in-person visits can offer important therapeutic benefits not gleamed through a televisit encounter.

As Dr. Clear points out, “What’s most important is that we work with the patient to find out what format they prefer and is likely to support their recovery.

Putting it all together

Dr. Clear re-emphasizes an important message, “Bottom line is: we know medication works so most patients should be on an effective medication. The behavioral component of treatment is also crucial but looks very different from person to person -- individual or group therapy; twelve-step meetings; peer support; a self-guided plan for healthy living including exercise, eating healthfully, and sleeping well; and the list goes on.”

He wraps up, “Addiction is a chronic lifelong condition, and treatment generally should be long-term but doesn’t have to be hard work.  Effective treatment can also be liberating and uplifting, then ultimately a simple routine.  Once patients reach out and seek recovery support, they often find themselves happier, healthier, and leading more fulfilling lives.”

Bicycle Health offers buprenorphine/naloxone (Suboxone) exclusively via televisits through either individual prescribing or group-based treatment.  We have a team of Suboxone-prescribing providers and clinical support specialists to help our patients in their recovery journey.

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.

Header Photo by Daria Shevtsova from Pexels

About the Author

Randi Sokol, MD, MPH, MMedEd

Randi Sokol, MD, MPH, MMedEd, is an Assistant Professor at the Tufts Family Medicine Residency Program and Instructor at Harvard Medical School. She is Board Certified in both Family Medicine and Addiction Medicine. She earned her B.A. at the University of Pennsylvania, her Medical Degree and Masters in Public Health from Tulane University, completed Family Medicine Residency at UC-Davis, and earned a Masters in Medical Education through the University of Dundee.

Citations

(2) Carroll KM, Weiss RD. The role of behavioral interventions in buprenorphine maintenance treatment: a review. Am J Psychiatry. 2016;174(8):738–47.

(3) Miller WR, Rollnick S. Motivational Interviewing Helping People Change. 3rd Edition. 2013. the Guilford Press, New York: New York.

(4) Naar-King S, Suarez M. Motivational Interviewing with Adolescents and Young Adults (Applications of Motivational Interviewing) 2011. The Guilford Press, New York: New York.

(5) Stuart MR, Lieberman III JA, Seymour J. The Fifteen Minute Hour: Therapeutic Talk in Primary Care, Fourth Edition 4th Edition. 2008. Radcliff Publishing Limited. United Kingdom.

(6) McHugh RK, Hearon BA, Otto MW. Cognitive behavioral therapy for substance use disorders. Psychiatr Clin North Am. 2010;33(3):511-525.

(7) Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 34.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK64947/

(8) https://www.mirecc.va.gov/visn16/docs/therapists_guide_to_brief_cbtmanual.pdf

(9) Meyers RJ, Roozen HG, Smith JE. The community reinforcement approach: an update of the evidence. Alcohol Res Health. 2011;33(4):380-388.

(10) https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Community-Reinforcement-Approach-Summary-2017-en.pdf

(11) https://www.drugsandalcohol.ie/13609/1/NTA_Community_reinforcement_approach.pdf

(12) Prendergast, M.; Podus, D.; Finney, J.; Greenwell, L.; and Roll, J. Contingency management for treatment of substance use disorders: A meta-analysis. Addiction 101(11):1546–1560, 2006.

Supplemental Information: National Institute on Drug Addiction (NIDA) website: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies/contingency-management-interventions-motivational-incentives

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