Overcoming the Stigma of Using Suboxone to Treat Opiate Dependence

September 2, 2022

Table of Contents

For patients who struggle with opioid use disorder (dependance on opioid drugs like oxycodone, hydrocodone, fentanyl, and heroin), seeking help can feel incredibly daunting. How can we help combat stigma and misinformation and support patients in their recovery?

In this article, we hope to debunk some common misconceptions about opioid use disorder (OUD), 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. We also know that patients in recovery are likely to deal with periods of relapse.[1] While it is very possible to be in “long term recovery” - abstaining from use for months, years or even indefinitely, there may be people who are never able to achieve full abstinence. 

“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 willpower.  Instead, it is like other chronic diseases, such as high blood pressure, asthma, and diabetes. 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: Detox is all that is required to overcome OUD


Detoxification is only the first stage of treatment, and it is rarely sufficient by itself to lead to long-term recovery.  In fact, the American Society of Addiction Medicine (ASAM) recommends against “detox” without the concurrent use of medication assisted treatment:

Dr. Clear explains, “When a person who is used to taking opioids, like Percocet 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 (Vivitrol) — are so important in recovery.

If a person has detoxed and doesn’t start on one of these medications, they have a dramatically higher chance of relapsing within 60 days.[2,3] Robust scientific evidence supports that these medications work to prevent relapse, overdose, and death.[4,5]

Misconception #3: Suboxone is 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.[6,7] It also has a ceiling effect, so even if a patient takes too much, they will not feel high and they will not overdose. It is thus considered very safe and effective.

Dr. Clear explains, “The thing I always ask my patients when they are concerned that buprenorphine being 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.  I then ask, ‘How do you feel the next morning before you take buprenorphine?” And the answer is the same — no cravings, no withdrawal symptoms, 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, it should be taken every day.”

Misconception #4: You will have to take Suboxone forever.

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 life — 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 can 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 they do get stressed or encounter triggers, they can employ healthy coping mechanisms and avoid relapse.”

Recent scientific recommendations suggest that patients should be on medications like buprenorphine as long as they need to be. There is no rush to come off them.[10]

Each individual can decide how long they need to be on Suboxone. While it is generally recommended that patients remain on these medications for months at the very least to make sure they are very stable, some patients may only need a few months of therapy while others may need years or even life long treatment. 

Misconception #5: If you use Suboxone, you are not “sober”. 

Suboxone is technically an opioid, meaning that it works on the same receptors triggered by drugs like heroin and OxyContin. This means that there can be some degree of physical dependence on Suboxone, particularly over time.

Addiction is a chronic disease of brain chemistry. People using Suboxone are treating their addiction and amending chemical imbalances. They rarely feel altered or “high
on their medication. Instead, they just feel normal, and are able to work on their recovery, and participate positively in their communities.

Many people are on psycho-active medications that have the potential to cause some degree of dependence. For example, anti-anxiety medications, antidepressants, antipsychotics, etc. all cause some degree of dependence, yet we do not tell people on these medications that they are “not sober”. Instead, we actually applaud them for getting the help they need. The addiction community agrees that we need to re-appraise the way we think about Suboxone and MAT similarly. 

Misconception #6: People misuse their Suboxone.

Almost three-fourths of people given a buprenorphine prescription do not misuse their medication. Those who do take higher doses than prescribed are often not trying to get “high” at all  (in fact, Suboxone does not really work to get people “high” due to its ceiling effect). Instead, they may simply be trying to relieve symptoms of physical pain or withdrawal symptoms. [11] In these cases of misuse, instead of punishment, their untreated pain or withdrawal symptoms should be addressed by their doctor by appropriately adjusting their dose.

Misconception #7: It’s easy to overdose on Suboxone.

Suboxone is actually quite difficult to overdose on. The few instances in which a person has overdosed on Suboxone usually occur when the patient has actually ingested other substances simultaneously. Thus, practically no deaths have been attributed to overdosing on Suboxone alone.

Suboxone has two built-in protections against overdose. First, the medication's ceiling effect means its effects stop working after a certain dose so people do not continue to get more and more sedated even if they accidentally or intentionally take more than their prescribed dose. Second, if a patient does intend to misuse Suboxone by injecting it, the built-in Naloxone component of the medication becomes active and binds to receptors in the brain, preventing overdose.

People who are opioid-naïve can feel dizziness, sedation or euphoria when they take Suboxone. But people using the medication for an addiction have plenty of experience with opioids and the effects are therefore even more minimal than in an “opioid naive” individual. They are at extremely low risk of overdosing from Suboxone.

Misconception #8: You can't use Suboxone & go to 12-step groups.

Many 12-step programs, such as Narcotics Anonymous, are based on the concept of strict sobriety. People participating in these programs promise they will not use substances like alcohol or heroin. If they do so, they may be asked to leave meetings or face consequences.

Suboxone is different. Many substance abuse treatment programs combine 12-step meetings with medication.[12] If you take your medication as prescribed by a professional, you can go to your support group meetings right on schedule.

Most twelve step programs have updated their policies to reflect our improved societal understanding of addiction disorders, and now do allow members to be actively in treatment with either Methadone or Suboxone. 

How Can We Reduce Misconceptions?

These days in addiction medicine, we know a few things quite certainly: 

Patients who are not on medications for opioid addiction have high rates of relapse. 

Buprenorphine/naloxone (Suboxone) is a safe and effective treatment for opioid addiction; it helps patients feel normal and gives the brain a chance to rewire so patients can go about living their lives. 

However, stigma and misinformation still exists, in spite of the medical community’s attempts to re-educate our population. 

Here are some tips on how to reduce stigma surrounding MAT:

  • Educate those around you about your recovery. Let them know you are in recovery and working hard every day.
  • Let them know that medication treatment has a science-backed record of success. Abstinence-only addiction treatment does not.
  • Remember that recovery is a marathon and not a sprint. No one should expect results overnight. The mantra “one day at a time” and even “one hour at a time” can set a more realistic approach to recovery.
  • Use a different language. Language choices can help eliminate the negative associations that we have developed around drug use. For example, in the medical community, we try to use the words “opioid use disorder” instead of “addiction”, or “drug misuse” instead of “drug abuse”. Subtle changes in language can help us dissociate words and phrases that carry stigma.


Support Groups for Loved Ones

Your loved one can gain information and support at these support groups targeted at friends and family of those struggling with addiction and in recovery:

Medically Reviewed By Elena Hill, MD, MPH

Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where she works as a primary care physician as well as part time in pain management and integrated health. Her clinical interests include underserved health care, chronic pain and integrated/alternative health.

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Citations

  1. Drug Dependence: A Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. JAMA. https://pubmed.ncbi.nlm.nih.gov/11015800/. October 2000. Accessed August 2022. 
  2. Discontinuation of Buprenorphine Maintenance Therapy: Perspectives and Outcomes. Journal of Substance Abuse Treatment. https://pubmed.ncbi.nlm.nih.gov/25601365/. May 2015. Accessed August 2022. 
  3. Primary Care-Based Buprenorphine Taper vs. Maintenance Therapy for Prescription Opioid Dependence: A Randomized Clinical Trial. JAMA Internal Medicine. https://pubmed.ncbi.nlm.nih.gov/25330017/. December 2014.  Accessed August 2022.
  4. Risk of Death During and After Opiate Substitution Treatment in Primary Care: Prospective Observational Study in UK General Practice Research Database. BMJ. https://pubmed.ncbi.nlm.nih.gov/20978062/. October 2010. Accessed August 2022.
  5. Mortality Risk During and After Opioid Substitution Treatment: Systematic Review and Meta-Analysis of Cohort Studies. BMJ. https://www.bmj.com/content/357/bmj.j1550. April 2017. Accessed August 2022.
  6. Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update. Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/product/Advisory-Sublingual-and-Transmucosal-Buprenorphine-for-Opioid-Use-Disorder-/SMA16-4938. March 2016. Accessed August 2022.
  7. Effects of Buprenorphine/Naloxone in Opioid-Dependent Humans. Psychopharmacology. https://pubmed.ncbi.nlm.nih.gov/11351930/. March 2001. Accessed August 2022. 
  8. National Practice Guideline 2020 Focused Update. American Society of Addiction Medicine. https://www.asam.org/quality-care/clinical-guidelines/national-practice-guideline. Accessed August 2022.
  9. Association Between Trajectories of Buprenorphine Treatment and Emergency Department and In-Patient Utilization. Addiction. https://pubmed.ncbi.nlm.nih.gov/26662858/. May 2016. Accessed August 2022.
  10. The Next Stage of Buprenorphine Care for Opioid Use Disorder. Annals of Internal Medicine. https://pubmed.ncbi.nlm.nih.gov/30357262/. November 2018. Accessed August 2022.
  11. 11. Trends in and Characteristics of Buprenorphine Misuse Among Adults in the U.S. JAMA. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2785011. October 2021. Accessed August 2022. 
  12. 12. Suboxone: Rationale, Science, Misconceptions. The Ochsner Journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855417/. Spring 2018. Accessed August 2022.

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