Buprenorphine Naloxone & Naltrexone

I think the main practical point is that pharmacological treatment of opioid addiction is effective and yet not as easily available as it should be. Not all opioid use disorder (OUD) specialized treatment programs offer medication assisted treatment (I have a somewhat out of date report that in 2017 “only … 35.5% offered any single medication for opioid use disorder treatment. This is more recent information

“Though the benefits of providing medication for opioid use disorder are well-known, only 22% of people with opioid use disorder receive medications. Buprenorphine, one of these medications, helps reduce opioid misuse, decrease risk for injection-related infectious diseases, and decrease risk for fatal and non-fatal overdoses.

“Research has shown beyond a doubt that medications for opioid use disorder are overwhelmingly beneficial and can be lifesaving, yet they continue to be vastly underused,” said NIDA Director and senior author, Nora Volkow, M.D. “Expanding more equitable access to these medications for people with substance use disorders is a critical part of our nation’s response to the overdose crisis.”

Until last year, one barrier was that most doctors were not allowed to prescribe buprenorphine – a special waiver was required. This was a crazy policy reversed by the Biden administration. “the … Fiscal Year 2023 omnibus appropriations bill amended the Controlled Substances Act to eliminate the requirement that clinicians obtain a specific waiver to prescribe buprenorphine to treat opioid use disorder” ” buprenorphine remains a Schedule III controlled substance with restrictions on prescribing.”

Importantly suboxone buprenorphine and opiate antagonist naloxone is also Schedule III. This makes no sense as the naloxone reduces the risk of diversion and the risk that misused buprenorphine will cause an overdose (which is low in any case). Googling for [suboxone overdose] I get links only to buprenorphine overdose statistics (93% of deaths involve another drug too — 50% entanyl — buprenorphine alone about 75 deaths a year). The emergency treatment for opioid overdose is naloxone. The naloxone does not change the effectiveness of buprenorphine when used properly (pill or film under the tongue) but only if it is diverted and injected or snorted.

I have searched for [suboxone diversion]. as with [suboxone overdose] I get only references to buprenorphine. I am ignorant and, in particular, aware of no evidence that suboxone is ever diverted to recreational use or (especially harmful) use by people who are not yet addicted. Yet it is schedule III. Why ?

Aslo diverted Buprenorphine is not necessarily abused. It is also used by people who want to avoid heroin and fentanyl “

“A recent study from Ohio found an association between the use of non-prescribed buprenorphine and a decreased risk of overdose. 15 This study shows that the more often nonprescribed buprenorphine is used by those with OUD and, the less fentanyl or heroin is used, resulting in a lower risk of overdose.15 As such, the use of nonprescribed buprenorphine by those with OUD is directly related to the
decision not to purchase or use heroin.”

So what’s the problem ? Also also “The Risk of Misuse and Diversion of Buprenorphine for Opioid Use Disorder Appears to Be Low in Medicare Part D”

Some doctors advocate over the counter buprenorphine. I’m not there yet, but I sure see good reason to reduce restrictions on suboxone. For one thing, it should definitely be offered to opioid addicts in prisons and jails. Detoxification (withdrawal) does not end dependency. People generally relapse if forced to endure withdrawal. A key role of medically assisted treatment is blocking opioid receptors so the patient can’t get high — they do not work just by preventing symptoms of abstinence.

a better version of this post (also written by an MD) is here. The claim is that suboxone should be made available to all people who seek it and that it helps even if not combined with counseling.

The title of the post also refers to buprenorphine+Naltrexone. Naltrexone is absorbed unlike Naloxone, so it reduces the effect of buprenorphine. I still advocate a slow shift from Buprenorphine (with naloxone) to Naltrexone.