When you think of buprenorphine (Suboxone) treatment for opioid addiction, what comes to mind?
If you think of it as a detox aid, intended to help decrease the discomforts associated with withdrawal from heroin and other opioids of abuse, don't feel bad. This is a common misconception—one that many people spread. Although buprenorphine can certainly be used as a detoxification aid, that's not actually it's most functional purpose. In fact, buprenorphine (usually combined with naloxone to prevent misuse of the drug) is best used as a long-term treatment for opioid addiction recovery.
How Opioids Change The Brain
If you or someone you love has been affected by opioid addiction, you're probably already aware that addiction causes changes in the brain. Opiates in particular create a physical dependency alongside a psychological addiction, making them especially difficult to stop using. Drugs like heroin and prescription pain pills like oxycodone latch onto our natural opioid receptors, which are integral to many bodily functions such as our pain and pleasure responses, sleep regulation—even breathing. Normally, our brain creates natural opioids, but when we become habituated to external opiate drugs, our bodies stop producing them at the normal rate, leading to a host of issues that manifest as acute withdrawal and can linger as post-acute withdrawal syndrome (PAWS). Replacement therapies correct some of those changes, helping the brain re-calibrate after addiction.
Methadone has been the gold standard opioid replacement therapy for decades, but buprenorphine has gained popularity in the past few years. Because it is a partial-opioid agonist, rather than a full agonist like methadone, it is less likely to cause fatigue and will be easier to taper from. Some rehab facilities taper patients from heroin or other short-acting opiates using decreasing doses of buprenorphine. Hence, the notion that buprenorphine is a "detox drug."
Patient Outcome For Long-Term Buprenorphine Use
Patients who use buprenorphine for six months or longer tend to have better outcomes than patients who use it only as a detox aid. While abstinence after detoxification is thought to have a relapse rate that can broach 90%, 60 to 90% of patients undergoing buprenorphine maintenance for a year or longer will remain in treatment. The same study even found that those patients who remained in treatment also had better measures of overall health, such as increased social function, and lower viral load in HIV positive patients.
Virtually all of the studies measuring the effectiveness of buprenorphine for long term use mention a need for additional psycho-social interventions. Addiction is considered a chronic relapsing brain disease. Those who challenge that definition still recognize that it is at least a psychological condition. Addiction likely has a genetic component, and it definitely causes changes in the brain. But environmental factors also play their part. At the very least, an opioid addiction will never be triggered in a body that has never been introduced to opiates. We also know that trauma and mental illness may play a role. For example, post-traumatic stress disorder is thought to be three times higher in patients with substance use disorders than the general population. This means that while medication-assisted therapy can help with the biological component of addiction, psychological interventions are also important.
Buprenorphine For Post-Traumatic Stress Disorder
Not a whole lot is known about the applications of buprenorphine for the treatment of PTSD, mostly because it has not been studied enough. Trauma therapists will tell you that if you have PTSD and are not addicted to opioids, you should not look to buprenorphine to manage your symptoms. That's because buprenorphine causes a dependency. But for someone who needs treatment for opioid addiction, and is therefore already dependent on opiates, buprenorphine may have some added benefits for PTSD. A small study on veterans with co-occurring PTSD and opioid dependency found that buprenorphine helped ease some symptoms of both disorders.
In my experience, buprenorphine has helped with both my post-traumatic stress disorder and my opioid addiction. PTSD compounds opioid addiction. It's well known among the medical community that patients with co-occurring PTSD and SUD have worse outcomes. For me, detoxing came with an added component of hopelessness, because I knew that even if I beat my heroin addiction, I would still have all that trauma to deal with.
I felt worse during periods of abstinence than I do now on buprenorphine/naloxone. I almost felt as though I were still using, but without the benefits of getting high. I was moody, volatile, and suicidal. Eventually, I relapsed. Buprenorphine has not eliminated my PTSD symptoms, but it has definitely helped manage them, while also reducing opiate cravings.
The Misuse Potential Of Buprenorphine
Buprenorphine has some potential for misuse. Buprenorphine does offer the possibility of getting high when not combined with naloxone, which is not bioavailable when ingested orally but becomes activated if a user attempts to inject the drug. When I was still in my active addiction, I injected buprenorphine tablets occasionally. My partner and I used to say it was "better than nothing." The high was pretty dreary, but because we were addicted not just to euphoria but also to the ritual of injection drug use, we felt it was worth it when we couldn't get anything else. So yes, it's possible to misuse buprenorphine.
For this reason, most addiction specialists will recommend that buprenorphine only be prescribed in concert with naloxone. Naloxone is also the drug found in Narcan, which is used to reverse overdoses. When added to buprenorphine, it prevents misuse by making it impossible to inject the drug and feel effects. Essentially, the naloxone cancels out the buprenorphine. People can still misuse buprenorphine by selling their strips or exchanging them for heroin, but those are decisions made by individuals. People who are committed to their recovery will use their buprenorphine correctly. Relapse may still happen; it's often a part of recovery. I've had my fair share. But because therapeutic doses of buprenorphine block the euphoric effects of other opiates, relapse becomes a lot less appealing when buprenorphine is used long-term.
Ultimately, buprenorphine is a helpful drug for people who are committed to sobriety from addictive opiates. While it does create a dependency—similar to insulin or antidepressants—it helps users move away from addictive behaviors and re-build their lives. Patients who use buprenorphine long-term tend to have better outcomes than patients who simply use it to detox. That doesn't mean it has to be lifelong, but it can be. If you eventually decide to taper, a gradual decrease that is supervised by your doctor will give your brain a better chance to heal and leave you with fewer withdrawal symptoms.
Workit Health provides Suboxone in Michigan & California.
Elizabeth Brico is a freelance writer with an MFA in Writing & Poetics from Naropa University. Her blog, Betty's Battleground, was recently ranked by Feedspot as one of the top 75 PTSD blogs. She is also a regular contributing writer for HealthyPlace's trauma blog. Her work has appeared on Vice, Vox, Stat News, The Fix, and others. When she isn't working, she can usually be found reading, writing, or watching speculative fiction.