Effects of Suboxone on People Who Use Fentanyl

April 18, 2024

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Understanding Suboxone

Suboxone is a medication that plays a significant role in the treatment of opioid dependence, including dependence on powerful opioids like fentanyl. It is crucial to understand what Suboxone is, its classification, and the implications of its long-term use when exploring its effects on people who use fentanyl.

Suboxone: Treatment and Classification

Suboxone, a combination of buprenorphine and naloxone, is an effective treatment for reducing opioid misuse. It has proven to be effective in keeping people with opioid dependence in treatment over a period of 24 weeks. As such, Suboxone is often a go-to medication for healthcare providers treating patients with opioid dependence.

Despite its therapeutic benefits, Suboxone is a controlled substance and is classified as a Schedule III prescription drug. This classification is due to its potential for physical and psychological dependence and risk of misuse. It is important to note that while Suboxone helps manage opioid dependence, it also carries its own risk of dependency.

Long-Term Use of Suboxone

Suboxone is often used long term for maintenance treatment of opioid dependence. It works to reduce severe withdrawal symptoms and drug cravings, making the journey to recovery more manageable for individuals grappling with opioid dependence [1].

However, long-term use of Suboxone is not without potential side effects. Some individuals may experience mild or serious side effects, including constipation, headache, weight gain or loss, rash, sweating, hair loss, insomnia, and liver damage. It is important for individuals to work closely with their healthcare providers to monitor these side effects and manage any health concerns that may arise.

Furthermore, combining Suboxone with benzodiazepines or other substances such as opioids, alcohol, or benzodiazepines can increase the risk of severe side effects, including coma and death. This highlights the importance of using Suboxone under the guidance of a healthcare provider and avoiding any potential dangerous drug interactions [1].

Overall, understanding Suboxone - its role in treatment, its classification, and the implications of its long-term use - is crucial when considering the effects of Suboxone on people who use fentanyl. This foundational knowledge provides the context needed to delve further into the interaction between Suboxone and fentanyl, and its impact on individuals with opioid dependence.

Side Effects of Suboxone

Understanding the potential side effects of Suboxone is essential when discussing its impact on fentanyl users. Suboxone can cause mild to severe reactions and has potential risks and interactions when taken with other substances.

Mild and Severe Reactions

Suboxone can cause a range of side effects, some of which are mild, while others can be serious. Mild side effects may include constipation, headache, weight gain or loss, rash, and sweating. More severe side effects could include hair loss, insomnia, and liver damage.

Side Effect	Severity
Constipation	Mild
Headache	Mild
Weight Gain/Loss	Mild
Rash	Mild
Sweating	Mild
Hair Loss	Severe
Insomnia	Severe
Liver Damage	Severe

It's important to consider these potential reactions when evaluating the effects of Suboxone on people who use fentanyl.

Interactions and Risks

Taking Suboxone in combination with other substances can elevate the risk of severe side effects. For instance, using Suboxone with benzodiazepines, opioids, or alcohol can increase the risk of severe outcomes, including coma and death. Furthermore, buprenorphine, a key component of Suboxone, can cause life-threatening respiratory depression and death when misused or when used in combination with benzodiazepines or other central nervous system depressants.

These interactions highlight the need for careful administration and monitoring of Suboxone use, particularly among individuals who may be using or have used other substances such as fentanyl. Understanding the potential interactions and risks associated with Suboxone use is instrumental in mitigating adverse outcomes and promoting safer use of the medication. The severity of these risks underscores the importance of medical supervision and guidance when using Suboxone as part of a treatment plan for opioid use disorders.

Fentanyl: Potency and Effects

Fentanyl is a potent synthetic opioid that bears significant risks and side effects. To understand the interaction between Suboxone and Fentanyl, it's crucial to first grasp the potency of Fentanyl and the serious implications it brings.

Deadly Nature of Fentanyl

Fentanyl is a powerful synthetic opioid that is 50 to 100 times more potent than morphine. Its potency significantly contributes to the high incidence of drug overdose deaths in the United States [3].

The deadly nature of Fentanyl is further underscored by how it affects the body. A study by investigators at Harvard-affiliated Massachusetts General Hospital found that Fentanyl begins to impair breathing about four minutes before there is any change in alertness. This happens at drug concentrations that are 1,700-times lower than those causing sedation. This means that Fentanyl can stop a person's breathing before they even realize it.

The findings stress the dangerous nature of Fentanyl, indicating that no amount of Fentanyl would be safe outside of a clinical setting with trained specialists. This emphasizes the need for increased availability of medical observation or supervision units, naloxone, and other tools to reduce the risk of death among individuals with substance use disorder [4].

Addiction and Withdrawal

Fentanyl affects the brain by binding to the body's opioid receptors, causing the brain to adapt to the drug, diminishing its sensitivity. This leads to addiction, where drug seeking and use can take over a person's life.

Fentanyl use can lead to addiction due to its potency, and individuals can experience withdrawal symptoms if the drug is stopped. Withdrawal symptoms can be severe and uncomfortable, making it challenging for people to stop taking Fentanyl. These symptoms include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goosebumps, and involuntary leg movements. These symptoms can start a few hours after the last dose of the drug.

Treatment for Fentanyl addiction can include medications and behavioral therapies. These have been proven to be effective in managing Fentanyl addiction and helping individuals recover from substance use disorders. However, unique challenges arise when treating Fentanyl addiction with Suboxone, which is further explored in the next section of this article.

Buprenorphine in Opioid Treatment

In the context of opioid treatment, particularly when discussing the effects of suboxone on individuals who use fentanyl, it's crucial to understand the role of buprenorphine. Buprenorphine is a synthetic opioid used to treat both acute and chronic pain, as well as opioid use disorder (OUD). It is approved by the Food and Drug Administration (FDA) for the long-term management of OUD [5].

Mechanism and Uses

Buprenorphine serves as an agonist substitution treatment, replacing the opioid of abuse with a safer, controlled substance. Over time, the dosage is gradually tapered to allow for withdrawal from opioid addiction with minimal discomfort. Additionally, the Drug Addiction Treatment Act of 2016 permits physicians to prescribe buprenorphine for the treatment of OUD in an office-based setting, further expanding its accessibility.

Beyond its established uses in pain management and opioid treatment, buprenorphine also shows promise in treating various addiction disorders. For instance, when combined with naltrexone, it may potentially address cocaine addiction [5].

Dosing Considerations

Buprenorphine dosage is a key aspect of its effectiveness in opioid treatment. It is available in various forms and strengths, including oral formulations (sublingual tablets and buccal films), transdermal patches, and parenteral routes (subcutaneous implants and intravenous/intramuscular injections).

Recent studies suggest that the currently recommended daily dose of 16 mg of buprenorphine may be inadequate for controlling withdrawal and cravings in patients who used fentanyl. A retrospective cohort study found that patients prescribed a higher dose (24 mg) remained in treatment longer than those prescribed 16 mg. Among patients prescribed 16 mg, 59% discontinued buprenorphine treatment within 180 days compared with 53% of those prescribed 24 mg.

This indicates that a higher daily dose may better suppress withdrawal and cravings. Preclinical studies have shown that fentanyl downregulates opioid receptor expression to a higher degree than morphine, which may explain why higher doses of buprenorphine may be needed when treating patients exposed to fentanyl.

Future research should explore the relationship between fentanyl use and increases in the optimal buprenorphine dose. Understanding the mechanism of buprenorphine and the various factors affecting its dosage is critical in fully grasping the effects of suboxone on people who use fentanyl and in furthering the development of effective treatment strategies.

Suboxone and Fentanyl Interaction

The effects of Suboxone on people who use fentanyl can be significant, particularly if Suboxone is administered too soon after the use of a full agonist opioid like fentanyl.

Precipitated Withdrawal

Precipitated withdrawal can occur when an individual uses a full agonist opioid such as fentanyl, oxycodone, or heroin, and then takes buprenorphine/naloxone (Suboxone) too soon afterward. In this scenario, the buprenorphine, a partial agonist, binds preferentially over the full opioid, forcing the other opioid off the receptors. This action can cause the acute onset of withdrawal symptoms, generally within 30 minutes of administering buprenorphine [7].

These precipitated withdrawal symptoms are typically more severe than natural withdrawal symptoms. While often mild, these episodes can be life-threatening in the most severe cases, particularly if symptoms like nausea and diarrhea lead to dehydration. Furthermore, the discomfort of withdrawal can trigger illicit drug use to relieve symptoms, increasing the risk of overdose as drug tolerance decreases.

Managing Withdrawal Symptoms

Suboxone, which contains buprenorphine and naloxone, binds more strongly to receptors in the brain than full opioids, even though it is less potent. If someone takes a full opioid like oxycodone after already having Suboxone in their system, the protective effect of Suboxone can block much of the effect of the full opioid, including the "high" or euphoric feelings. This blocking ability of Suboxone is protective, but some individuals may misuse high doses of heroin or opioid painkillers in attempts to overcome this protection, leading to an increased risk of opioid overdose.

In managing precipitated withdrawal, the buprenorphine component of Suboxone binds to opioid receptors and displaces fentanyl from them. At the same time, naloxone, an opioid antagonist, also blocks the effects of fentanyl at the receptor site.

In some extreme cases, high doses of buprenorphine may be required for successful treatment. As noted in one case report, a patient required 148 mg of buprenorphine over 48 hours for successful treatment of buprenorphine-precipitated withdrawal, extending the known upper limit of buprenorphine dosing.

Understanding these interactions and effects is crucial in managing opioid addiction and facilitating safe and effective recovery. It highlights the importance of professional guidance and supervision in the use of Suboxone for opioid dependency treatment.

Clinical Insights and Future Research

Analyzing the effects of suboxone on people who use fentanyl involves examining clinical case studies and understanding the recommendations and clinical knowledge shared by credible sources such as the US Food and Drug Administration (FDA).

Case Studies and Treatment

A case report published by the NCBI describes the successful management of buprenorphine-precipitated fentanyl withdrawal using high doses of buprenorphine. The patient was administered a total of 148 mg of buprenorphine over the first 48 hours, averaging about 63 mg per day over four days. This treatment resulted in rapid improvement in withdrawal symptoms without notable side effects. The patient was able to reduce the dose to 16 mg twice daily by the time of discharge.

This case report reveals that the upper range of known buprenorphine dosing for the treatment of buprenorphine-precipitated withdrawal has been significantly extended. Previous case studies had used between 16 and 40 mg daily, while in this case, the patient required a total of 148 mg of buprenorphine over 48 hours for effective treatment.

FDA Recommendations and Clinical Knowledge

The FDA has approved the use of buprenorphine up to 32 mg daily for the treatment of opioid use disorder. At this dose, the mu-opioid receptor nears saturation. Despite this, the actual duration of buprenorphine's action is only 6-8 hours, which might partially explain the effectiveness of repeated high doses.

However, there is a need for further research to close clinical knowledge gaps and provide clarity to clinicians. Additionally, other options for the treatment of acute buprenorphine-precipitated withdrawal include symptomatic management or the use of full-opioid agonists such as methadone.

Importantly, the aforementioned case report underscores the significance of initiating buprenorphine treatment to preserve or reestablish confidence in this potentially life-saving medication. It also highlights the need to provide immediate relief to patients with opioid use disorder.

In conclusion, the exploration of clinical insights and future research is crucial to further understand the interaction between suboxone and fentanyl. This will guide the development of more effective treatment strategies and improve the outcomes for patients struggling with opioid use disorder.