Suboxone for Opioid Use Disorder: An Underutilized Lifesaving Treatment
INTRODUCTION
While opiates have been utilized for thousands of years, Opioid Use Disorder (OUD) has been increasing drastically since the turn of the 21st century. The disease is estimated to affect over 16 million people worldwide, with over 2.1 million of those being in the United States [1]. Overdoses have been continuing to increase in frequency throughout this time. Many of these patients will ultimately arrive in the Emergency Department following the life-saving reversal agent naloxone. However, it has been shown that this patient population has a one-year mortality rate of roughly 5% [2]. Despite this, this patient population experiences many barriers to treatment including, but not limited to, challenges to access, underlying stigma, and cost.
Figure 1: National Overdose Deaths Involving any Opioid (National Institutes of Health)
DISCUSSION
What is Suboxone?
Suboxone is a mixture of buprenorphine, a μ-opioid receptor partial agonist, and naloxone, an opioid antagonist with negligible oral absorption. The buprenorphine has high receptor affinity, subsequently displacing already present opioid agonists of lower affinity, such as fentanyl or heroin. Historically, there were barriers to prescription due to the required X-waiver, where providers needed approval to prescribe this medication. As of 2023, this waiver was removed within the Mainstreaming Addiction Treatment (MAT) Act [3].
Benefits:
Suboxone has been shown to be a successful treatment option for those suffering from OUD, with similar efficacy to methadone. Roughly 50% of patients on maintenance doses >16mg have been shown to remain on treatment (NNT: 2) [4]. Not only does it work well to suppress cravings, but also it is a more practical option for many patients when compared to methadone. While the latter requires daily visits to opioid treatment programs (OTPs), suboxone can be prescribed for consistent home use.
The medication itself has a favorable safety profile, primarily driven by its ceiling effect regarding respiratory depression. Buprenorphine’s analgesic effects increase with escalating doses while there is negligible change in minute ventilation. Due to this profile, there have even been recorded cases of suboxone reversing opioid withdrawal [5].
Considerations:
One of the greatest hesitations to prescribing suboxone is related to fears of precipitating withdrawal. Due to its high affinity yet partial agonism, buprenorphine replaces already saturated opioid receptors. The subsequent drop in opioid agonism can lead to immediate withdrawal symptoms (Figure 2). Because of this, the induction of this medication is only recommended in patients already exhibiting withdrawal symptoms. The Clinical Opiate Withdrawal Scale (COWS) is typically utilized and a score of at least 8 is recommended prior to initiation of suboxone.
The use of the medication has become more difficult with the emergence of fentanyl over recent years. Typically, the timing of withdrawal depends on the half-life of the opioid used. As an example, abstinence from methadone typically takes days prior to withdrawal symptoms due to its prolonged half-life. Fentanyl itself has a short half-life, of only 3-7 hours [6]. However, fentanyl is particularly lipophilic so chronic use can lead to metabolites being present for weeks. Because of this, there are reports of precipitating withdrawal with suboxone many days following last use.
Contraindications of the medication include liver impairment and concurrent use of CNS depressive medications such as ethanol or benzodiazepines. There were previously concerns regarding suboxone use during pregnancy for teratogenic effects. However, studies have failed to show any negative effects, and ACOG recommends its use.
Figure 2: Opioid Agonism (National Alliance of Advocates for Buprenorphine Treatment)
Dosing:
Suboxone typically comes in sublingual films with 8 mg of buprenorphine and 2 Emg of naloxone. These can be cut into specific smaller doses as needed.
Many different regimens exist for the initiation of suboxone. Our institution recommends a starting dose of 8mg SL Buprenorphine (Figure 3). If still symptomatic but noting partial relief, patients may require a second 8mg dose. Ultimately, patients should receive a prescription for 16mg daily with follow-up with a recovery center for further care and management. Recent data has shown improved outcomes with higher maintenance doses of suboxone, so this will likely change in the upcoming years [7].
Figure 3: Lifespan Buprenorphine Algorithm
AUTHOR: J. Kyle Volpe, MD, is a fourth-year emergency medicine resident at Brown Emergency Medicine Residency
FACULTY REVIEWER: Michelle Myles, MD is an attending physician and clinician educator at Brown Emergency Medicine
References
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