Overcoming the Stigma of Using Suboxone to Treat Opiate Dependence

October 21, 2020

“It’s really hard for me,” says Justin (psuedo-name used to protect confidentiality), a patient who was addicted oxycodone for 5 years and has now been on Buprenorphine/naloxone (Suboxone) and in recovery for the past 6 months at Bicycle Health.

“I have been taking my Suboxone every day, and I’m back to working again and feel much more in control--like I’m doing the right thing. But, my family still does not see it that way.  They still don’t trust me, and my friends think I’m just trading one drug for another and that I need to try harder and really get clean.”

Justin is certainly not alone.

For patients who struggle with opioid use disorder—addiction to drugs like oxycodone, hydrocodone, fentanyl, and heroin—acknowledging they have a problem and seeking help can feel incredibly daunting.  When this is compounded by good-intentioned friends and family who care but do not fundamentally understand addiction, a patient can feel alone, unsupported, and questioning their recovery.

So, how can we help combat stigma and support patients in their long-term recovery efforts?

In this article, we hope to debunk some common misconceptions about addiction to opioids, Buprenorphine/naloxone (Suboxone), and recovery.  We also provide tools and resources to help support patients and their family and friends.

Misconception #1: Addiction is a “curable” disease.

While addiction was once thought to be a “curable” disease,  we now know that it is a chronic “bio-behavioral disorder,” meaning that it has lifelong effects on a person’s physical, mental, and emotional health. And, we know that patients in recovery are likely to also battle periods of relapse (1). 

“We have really evolved our understanding of the brain disease of addiction,” says Bicycle Health’s Chief Medical Officer, Dr. Brian Clear.  “Over the past several decades, studies have demonstrated that addiction is not a defect of morals or will power.  Instead, it is like other chronic diseases, such as high blood pressure (hypertension), asthma, and diabetes, and patients experience bouts of both relapse and recovery and that is normal.”

As this graph shows, relapse during addiction has similar rates to other chronic diseases.



Misconception #2: “I can just go to detox and then be done, right?”

Detoxification is only the first stage of treatment and is rarely sufficient by itself to lead to long-term recovery.  In fact, the American Society of Addiction Medicine (ASAM), recommends against detox.  Why is that?

Dr. Clear explains, “When a person who is used to taking opioids—like percocets or fentanyl—goes into detox and comes out, their brain’s opioid receptors lose tolerance to opioids.  If that person then relapses, their brain becomes overwhelmed with opioids which can lead to an overdose and even death.”

That’s why evidence-based medications that help with opioid use disorder—like methadone, Buprenorphine/naloxone (Suboxone) and naltrexone (aka vivitrol)—are so important in recovery.

If a person is detoxed and is not started on one of these medications, they have a 90% chance of relapsing within 60 days (2,3). However, when started on a medication, 40-60% of patients will still be doing well 1 year after detox. Bottom line, robust scientific evidence supports that these medications work to prevent relapse, overdose, and death (4,5). 

Misconception #3: But, isn’t Suboxone just trading one drug for another?

Buprenorphine/naloxone (Suboxone) is considered an evidence-based treatment for opioid use disorder.

As a partial-agonist, it binds to the opioid receptors of the brain, partially stimulating them so a person does not feel cravings or withdrawal while blocking the brain from things like oxycodone and fentanyl (6,7).

It also has a ceiling effect so that even if a patient takes too much, they will NOT feel “high” and they will NOT overdose.  It is thus considered very safe and very effective.

Dr. Clear explains, “The thing I always ask my patients when they are concerned that buprenorphine is a replacement of one drug for another is ‘How do you feel after you take  buprenorphine each morning?’ They usually tell me that they feel normal-- not high, not sedated, just normal.  Then ‘How do you feel the next morning, before you take buprenorphine?”  And the answer is the same-- no craving, no withdrawal, just normal.  That’s nothing like other opioid use.”

He further elaborates, “I see buprenorphine like I see medication for diabetes and high blood pressure. If taking it each morning helps my patients get up and go to work, pay their bills, reconnect with their values, enjoy life, and take better care of themselves, then it should be taken every day.”

Misconception #4 “But, I will have to be on this for life. It feels like handcuffs!” 

After patients have become addicted to opioids, their brains get biochemically rewired through various pathways that involve reward, memory, and mood. It thus takes a while to rewire these pathways: It usually takes a minimum of 6 months to start to rewire and at least 18 months for the pathways to operate closer to normal (8,9). 

“This is really a marathon and not a sprint,” Dr. Clear explains.  “It takes years for a person to rebuild their lives—to develop routines like working, a support system of trusting family and friends, and healthy coping mechanisms.” 

He elaborates, “Treatment with Suboxone allows stabilization of opioid receptors so that patients are able to make changes in their lifestyle to allow ultimate recovery rather than cycles of relapse. Medications should be coupled with treatment approaches-- like therapy, exercise, relaxation strategies, spiritual connections, sleep, good nutrition, and overall self care, so that when patients do get stressed or have triggers, they can employ healthy coping mechanisms and avoid relapse.”

Recent scientific recommendations also suggest that patients should be on medications like Buprenorphine ‘as long as they need to be’ and there is no rush to come off it (10). 

More FAQ from the American Association of Addiction Psychiatry (AAAP)’s Provider Clinical Support Services (PCSS) website.

So knowing what we do—that patients NOT on medications for opiate addiction have high rates of relapse; that Suboxone is a safe and effective treatment for opioid addiction; that it helps patients feel normal and gives the brain the chance to rewire so patients can go about living their lives—how do we combat stigma and respond to family and friends who remain skeptical?

Some Tips

  1. Educate those around you about your recovery.  Let them know you are in recovery and working hard every day.
  2. If they ask about Suboxone, let them know that medication treatment has a science-backed record of success. Abstinence-only addiction treatment does not. 
  3. Remember, as Dr. Clear pointed out, “this is a marathon and not a sprint.” Rather than feeling daunted and pressured to get back on track and back to the values and lifestyle you aim to achieve, remember that you should not expect results overnight.  The mantra “one day at a time” and even “one hour at a time” can help set a more realistic approach to recovery.
  4. Remember that it may take awhile to regain your friends’ and family’s trust.  While it might feel frustrating when they judge you, you can take control by FOCUSING ON YOU and nourishing your recovery by doing things like, like getting into an exercise routine, seeing a therapist, attending 12-step meetings (like AA/NA, Smart Recovery), getting a sponsor, eating healthy, sleeping well, seeing your doctor and taking care of yourself.  It’s okay to prioritize yourself!  That’s what recovery is about.  It has to be a daily effort! Though it might take awhile, your behaviors will eventually demonstrate to others how far you have come.  But that’s not why you are doing this; stay true to yourself and others will see the results.
  5. Help change language so that others realize that addiction is a chronic, lifelong brain disease, that relapse often occurs and is part of the recovery process, that treatment should be ongoing, and that you need their support to optimally embrace recovery.  Consider this framework:


If you are a family member or friend of a patient struggling with opiate addiction here are several resources

Support Groups

Online Resources


Bicycle Health uses Suboxone in its treatment program to achieve proven success. 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.

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

  1. McLellan AT , Lewis DC , O'Brien CP , and Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284:1689-95.)
  2. Bentzley BS , Barth KS , Back SE , and Book SW . Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes. J Subst Abuse Treat. 2015;52:48-57.
  3. Fiellin DA , Schottenfeld RS , Cutter CJ , Moore BA , Barry DT , and O'Connor PG. Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: a randomized clinical trial.JAMA Intern Med. 2014;174:1947-54.
  4. Cornish R , Macleod J , Strang J , Vickerman P , and Hickman M . Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database. BMJ. 2010;341:c5475.
  5. Sordo L, Barrio G, Bravo MJ, et al. 2017. Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. British Medical Journal 357:j1550.
  6. Substance Abuse and Mental Health Services Administration (SAMHSA). 2016. Sublingual and transmucosal buprenorphine for opioid use disorder: review and update. Advisory 15.
  7. Stoller KB, Bigelow GE, Walsh SL, Strain EC. 2001. Effects of buprenorphine/naloxone in opioid-dependent humans. Psychopharmacology (Berl) 154(3):230‒242.
  8. Kampman S, Comer S, Cunningham C, et al. 2015. National practice guideline for the use of medications in the treatment of addiction involving opioid use. Chevy Chase, MD: American Society of Addiction Medicine.
  9. Lo-Ciganic WH, Gellad WF, Gordon AJ, et al. 2016. Association between trajectories of buprenorphine treatment and emergency department and in-patient utilization. Addiction 111(5):892–902.
  10. Martin S, et al.The Next Stage of Buprenorphine Care for Opioid Use Disorder. Annals of Internal Medicine. 2018.

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