Subutex is a tablet of buprenorphine hydrochloride that dissolves under the tongue. Buprenorphine, an opioid drug, is useful for treating opiate addiction.
It is also a potent anesthetic, 20 to 50 times as powerful as morphine, reports the Substance Abuse and Mental Health Services Administration (SAMHSA). Like any opiate, it has the potential for abuse.
Since buprenorphine was approved by the FDA in 2002 to treat opiate abuse, SAMHSA has found that it has grown in popularity from about 100,000 prescribed users in 2005 to over 800,000 users with prescriptions in 2010. In total, the Drug Enforcement Administration (DEA) reports that 9.3 million prescriptions for buprenorphine were dispensed in the United States in 2012.
Use in Addiction Treatment
Buprenorphine offers a safer alternative for people who are addicted to heroin or other opioids and looking to quit without experiencing withdrawal symptoms. On Subutex, people can gradually reduce their dosage and taper off opioids until they are drug-free. Subutex is not suitable for opioid maintenance treatment – the U.S. National Library of Medicine reports that a mixture of buprenorphine and naloxone (Suboxone) is preferred for long-term opioid maintenance treatment, as the naloxone reduces the risk of abuse.
The U.S. National Library of Medicine further explains that Subutex is a tablet that must be taken by holding it under the tongue until it dissolves, which takes about two to 10 minutes. Chewing or swallowing the tablet will reduce its absorption into the body. If multiple tablets are prescribed, they can be taken two at a time or all at once. According to the DEA, the effects of Subutex last 24 to 72 hours.
It is possible to overdose on buprenorphine or have other medical complications, especially if it is abused – that is, combined with other drugs or alcohol, or taken in doses exceeding, or without, a doctor’s prescription. SAMHSA reports that the number of emergency department visits involving buprenorphine rose from 3,161 visits in 2005 to 30,135 visits in 2010. In 2010, 15,778 visits – over half – were for buprenorphine that was used non-medically. Fifty-nine percent of these involved another drug such as benzodiazepines, like Xanax, and 27 percent involved illegal drugs like marijuana.
A national survey of buprenorphine abusers in the Journal of Opioid Management found the following facts on users:
- 1 percent white, 3.8 percent Hispanic, 1.5 percent African-American, and 2.7 percent other
- 30 years old on average
- 7 percent have a college degree and 40 percent have only a high school degree
- 4 percent are employed
- 7 percent get their buprenorphine from a doctor, 34.6 percent get it from a dealer, and 23 percent get it from a friend (some from multiple sources)
Few people receive treatment for buprenorphine abuse specifically. SAMHSA found that out of 1,469,165 people admitted for drug abuse treatment in one survey, only 19 were admitted for buprenorphine abuse, either as a primary or secondary substance of abuse.
Subutex and the Brain
Buprenorphine is an opioid drug, meaning that it mimics the body’s endorphins and binds to sites in the brain called opioid receptors. Its mechanism of action is more complicated than opioids like morphine; however, buprenorphine only partially activates the mu-opioid receptor and actively blocks the kappa-opioid receptor, according to the U.S. National Library of Medicine. This means that while it will cause some opioid effects at low doses (such as anesthesia or euphoria), higher doses won’t have any additional effects, in a condition called a plateau or ceiling effect. This reduces the risk of abuse and overdose. Additionally, buprenorphine will outcompete other opioids to bind to receptors, reducing their effects and triggering withdrawal when used in high doses.
The National Institute on Drug Abuse (NIDA) describes how opioid drugs cause addiction. The endorphin system in the brain is linked to the dopamine system, which controls motivation and reward. Opioid drugs like Subutex boost the amounts of dopamine that the brain releases. Elevated dopamine levels cause feelings of pleasure and euphoria, but also cause changes in the downstream nerve cells. The cells become desensitized to the effects of dopamine until the normal levels of dopamine that the brain uses are insufficient for the brain to work properly – it now needs opioids in order to function, in a state called dependence.
Dependence alone isn’t sufficient for addiction – it can occur as part of normal treatment with buprenorphine. However, abuse sets in when Subutex is used without a prescription, or in doses greater than or more frequently than the prescription allows. This can lead to addictive behaviors.
Signs that Subutex use has turned into addiction include:
- Using Subutex in larger doses than directed
- Using the drug more frequently than directed
- Using the drug to get high instead of to help avoid using other opiates
- Using Subutex without a prescription and a doctor’s approval
- Repeatedly seeking a prescription for Subutex despite multiple doctors refusing to prescribe it
- Feeling cravings to use more of the drug
- Difficulty reducing dosage as directed
- Feeling like Subutex use has gotten out of control
- Giving up hobbies and pastimes in order to spend more time using the drug
- Missing obligations and responsibilities, like work or family events, because of Subutex use
- Spending substantial time recuperating from being high on or withdrawing from the drug
- Continued use of Subutex despite it causing physical or mental health problems
- Continued use of the drug despite it causing social or legal consequences
- Using Subutex in situations when being high on opioids might be physically dangerous, such as while operating machinery or driving a car
The Journal of Opioid Management found that buprenorphine abusers used a variety of administration methods (often multiple):
- 87 percent used buprenorphine sublingually, as the tablet is meant to be taken
- 15 percent swallowed the tablet
- 12 percent chewed the tablet
- Nine percent crushed and sniffed the tablet
- Six percent crushed, dissolved, and injected the tablet
- Three percent crushed and smoked the tablet
To help Subutex users who are at risk for abusing buprenorphine, prescribing doctors should take precautionary measures such as not offering refills and carefully tracking how often the prescription is renewed. This will also help doctors ensure that Subutex is not being diverted for use by someone else.
The Hazards of Subutex Abuse
In addition to the risk of addiction, Subutex users are at risk for:
- Overdose. Although it is difficult for medical users to overdose on buprenorphine alone, it can make for a deadly combination when taken with alcohol, benzodiazepines or other drugs that depress breathing or the activity of the central nervous system. Opioid-naïve users, who do not have a history of opiate use, may be at risk for overdose if they take Subutex. Overall, however, buprenorphine isn’t as dangerous as many other opioids – the DEA reports that out of 3,625 case mentions of buprenorphine by US poison control centers in 2011, there were only three deaths.
- Reduction in breathing. All opiates can reduce breathing, and buprenorphine can do so when taken in excess or when combined with other drugs. This breathing impairment can be fatal, especially in people with pre-existing respiratory conditions like asthma or COPD. Children are particularly vulnerable to this, so Subutex should be kept out of their reach.
- Interactions with other drugs, especially benzodiazepines, alcohol and other sedatives. These can drastically increase the risk of respiratory reduction and complications, as well as overdose.
- Liver problems. Buprenorphine has been linked to liver inflammation and failure, reports the S. National Library of Medicine. People taking buprenorphine should have their liver function monitored, especially if they have a pre-existing liver condition like hepatitis B or C.
- Allergic reaction. Some people experience allergic symptoms in response to buprenorphine, such as rash, hives, bronchospasm or anaphylactic shock.
- Elevated fluid pressure inside the skull. This can make Subutex use dangerous in patients who have experienced head injury or brain tumors.
- Induced opiate withdrawal can occur if they have been taking opiates previously.
- Neonatal withdrawal syndrome can occur among infants born to women taking buprenorphine.
- Low blood pressure can occur which can cause dizziness or fainting.
Treatment for Abuse
People who abuse Subutex fall into one of two categories: people who currently have a prescription for the drug but are using it in addictive patterns, and people who do not have a prescription and get their Subutex from friends, dealers or other sources. There is some overlap – people who have a prescription for Subutex may get additional doses from a friend or dealer, and people who do not currently have a prescription may have had one in the past.
People who have a continuing medical need to keep using buprenorphine (called maintenance) should work with their doctor to figure out the best way to proceed. They may switch to Suboxone, a less-addictive form of buprenorphine that has naloxone as an added ingredient. This not only blocks the euphoric effects of buprenorphine, but it can also cause withdrawal symptoms if taken in excessive doses. Naloxone also acts more powerfully than buprenorphine when injected, meaning that if someone attempts to abuse Suboxone by injecting it, withdrawal will be triggered.
People who do not have a prescription for buprenorphine but feel it will help them avoid using more dangerous opioid drugs will benefit from seeking help. This group may represent a large percentage of illicit buprenorphine users – SAMHSA found that 58 percent of people who visited emergency rooms for buprenorphine-related reasons in 2010 had also used other opioid pain relievers, particularly oxycodone. Since adding buprenorphine to other opiates reduces, rather than increases, their potential high, many people using buprenorphine without a prescription may be attempting to self-medicate opioid dependence on their own. Considering their history of buprenorphine abuse, doctors may prescribe Suboxone instead of Subutex for such people when they do receive treatment.
Those who abuse buprenorphine who are unlikely to abuse other opioids or otherwise are unsuited for maintenance care are also encouraged to seek treatment. Working closely with a doctor, they can gradually reduce their buprenorphine use in a process called tapering. By tapering slowly, they can eventually reach a drug-free state without experiencing withdrawal symptoms.
Both switching to Suboxone maintenance and tapering off should be done under the guidance of a buprenorphine-certified prescribing doctor.
You or your loved one can receive treatment for buprenorphine abuse as part of a comprehensive rehabilitation program at The Oaks at La Paloma, located in Memphis, Tennessee. Our admissions coordinators are ready 24 hours a day to answer any questions you may have and walk you through our confidential intake process. By seeking help, you’ve made the right decision – learn more today.