How Long Should Patients Take Suboxone? Should You Take Suboxone Forever? Medical Experts Debate!
In the realm of opioid addiction recovery, the question of how long a patient should be on Suboxone is a matter that requires careful consideration. While some advocate for a long-term approach to maintain stability, others emphasize the importance of gradually tapering off of Suboxone. The decision hinges on factors like individual response to treatment, risk of relapse, and the availability of comprehensive support systems. To illustrate the arguments on both sides of the debate, I (theoretically) arranged an interview with two physicians (myself) to gather their thoughts.
Thad: How long is enough? How long should patients with opioid use disorder be on Suboxone?
Let’s introduce our guests: Dr John Felgood, a physician from Tampa, FL who works closely with patients with opioid use disorder Joining him is Dr Mark Allrite, an emergency physician who treats patients with addiction in his daily practice and also supervises a treatment pathway which identifies patients with addiction in the emergency department and starts them on treatment.
Thank you both for taking the time to speak tonight.
No sense in holding back, gentlemen. How long should patients with opioid addiction stay on Suboxone? Aren’t they just trading one addiction for another? Let’s start by passing the floor to Dr Allrite.
Dr. Allrite: Thank you, Thad. Suboxone, also known as buprenorphine-naloxone, has been nothing short of miraculous for the treatment of patients with opioid use disorder. It helps patients stop using dangerous street drugs and allows them to stabilize their lives. They can enter treatment and address the root causes of their addiction because Suboxone alleviates their withdrawal and cravings.
With that said, once a person has achieved recovery, they can and in many cases, should taper and stop their Suboxone. Each patient is an individual, but many people can attempt this taper after about 12-18 months, at which time they should be stabilized with therapy. What good is trading dependence on one substance for long-term dependence on another?
Thad: What say you, Dr Felgood?
Dr. Felgood: I agree with my colleague that Suboxone seems like a miracle drug. I’ve personally seen it completely transform the lives of my patients. Moreover, the scientific evidence suggests that Suboxone is life-saving because it prevents overdose and the medical complications of street drugs, like HIV and endocarditis.
Making Comparisons
Dr. Felgood: What he failed to mention, however, is the fact that patients experience a significant increase in their risk of death from all causes in the year after they discontinue their Suboxone. Patients who stop, even if they are medically supervised, are at much greater risk for overdose and other medical complications than those who continue taking the medication. The fact is that substance use disorder is a chronic disease and it’s not really helpful to think in terms of a “cure”; instead, we should think in terms of management, just like we do for other chronic diseases, like diabetes. We aren’t debating whether or not diabetics should stop their insulin, so why should we force people to stop Suboxone if it is working for them?
Dr. Allrite: It’s a little disingenuous to compare Suboxone to insulin, don’t you think?
Thad: Now, Dr. Allrite, it’s Dr. Felgood’s turn to speak.
Dr Felgood: No, Thad, it’s fine. Expand on your thoughts, Mark.
Dr. Allrite: Are we talking insulin for a type I diabetic, whose pancreas doesn’t produce any or insulin for a type II diabetic, whose body just doesn’t respond to their own insulin? That’s a big difference. No one suggests a type I diabetic stop their insulin, but we do motivate type II diabetics to change their diet and lifestyle with the goal of getting them off insulin. No one is born with an opioid addiction and people with opioid use disorder can participate in therapy to address their issues. After a certain point, the Suboxone is just being used as a crutch.
Thad: Wow, that’s such a good point! Do you think that Suboxone is a crutch, Dr Felgood?
Dr Felgood: Well, Thad, it’s a little ableist to hold up a crutch as an example of something undesirable. A lot of people with injuries or other disabilities use a crutch as a mobility aid. What would you say to a person who uses a crutch to navigate their world?
Long Term Side Effects
Thad: Shots fired! Dr. Allrite, what say you?
Dr. Allrite: Well, a crutch doesn’t have side effects like an opioid drug does. Long-term use of opioids is associated with many health consequences: decreased production of sex hormones like testosterone, chronic constipation, decreased bone density, sleep disorders, and adrenal suppression. Those are just the ones we know about; what happens to these people in 30-40 years?
Dr. Felgood: Well, I think “these people” would rather be alive in 30-40 years with those side effects rather than dead from an overdose. As I mentioned before, patients are four times more likely to die in the first year after stopping their medication for opioid use disorder. So I have to ask you, why are we doing this—why are we forcing people off their highly effective medications? Is it to prevent complications, or is it just because being abstinent is an ideological goal that comports to our pre-existing societal norms?
Society and Ideology
Thad: Touche! Dr. Allrite, are you suggesting addicts should risk their lives for ideological purity?
Dr. Allrite: Well, Thad, that’s a little unfair to say. I’m not suggesting that we force people off their Suboxone. If they want to stay on the medication, that’s their decision, and it should be respected. But we must inform them of the risks so they can make an informed decision. And there are other options as well. You have yet to mention naltrexone, also known as Vivitrol, which is a long-acting injection that blocks opioid receptors and helps patients avoid relapse by removing the reward from using opioids. It also prevents overdose, which seems to be your major concern.
Vivitrol as an Alternative
Thad: Good point Dr Allrite. The question turns to you, Dr. Felgood; why haven’t you mentioned Vivitrol yet? If it prevents overdose deaths, why do patients need to remain on Suboxone? Do you have a financial stake in Suboxone?
Dr. Felgood: Thad, I disclosed my conflicts of interest to your producer, and I should reiterate that I have no financial stake in Suboxone. Did you take the time to read it? Regardless, the situation is actually the opposite of what you imply; Suboxone is now a generic drug, whereas Vivitrol remains on patent and is far costlier in comparison. If anything, the pharmaceutical industry has an incentive to push Vivitrol on patients.
Dr. Allrite: Are you suggesting a conspiracy to sell Vivitrol injections, John?
Dr. Felgood: Well, Mark, I can’t prove it, but it sure seems that Vivitrol’s manufacturer Alkermes has waged an expensive campaign to incentivize the use of their injection rather than other medications for opioid use disorder, especially in vulnerable populations like jail and prison inmates. They have gone as far as lobbying state governments to include Vivitrol in prison pharmacies and draft protocols encouraging its use in incarcerated people with opioid use disorder.
Dr. Allrite: It really sounds like you’re peddling conspiracy theories, John.
Dr. Felgood: Except this is all true and you can read about it yourself! Vivitrol is a useful drug, especially for certain patients who must avoid opioids entirely and have strong incentives to stay abstinent, like medical professionals and airline pilots. Still, it is clearly inferior to medications like Suboxone and methadone when studied in the general population of people with opioid use disorder.
Thad: If Vivitrol blocks all opioids and lasts for a month, how can it fail Dr. Felgood?
Dr. Felgood: Thad, thank you for asking that. Vivitrol blocks the high from opioids and prevents overdose, but it’s only effective if patients are regularly redosed. That’s the problem we’re seeing. Patients are more likely to drop out of treatment on Vivitrol because it does not satisfy their cravings to use. Once the drug wears off, the person can be more likely to overdose, as well, since their tolerance will have dropped.
Thad: Dr. Felgood is really making Vivitrol sound like a scam, Dr. Allrite.
Dr. Allrite: Is that what passes for a question on this program, Thad? No, it’s not a scam. I’m not suggesting that Vivitrol be used in favor of Suboxone or methadone as a first-line treatment. That’s not what I’m saying at all. I am saying that it can be the second phase of treatment after a patient has stabilized with therapy for their addiction and has tapered off Suboxone.
Final Thoughts
Thad: Okay, final words. Dr. Allrite has made his case; what’s your takeaway, Dr. Felgood?
Dr. Felgood: The goal of treatment for opioid use disorder is to decrease the risks of medical complications, overdoses, and death while improving the individual’s quality of life. Medications for opioid use disorder, like Suboxone and methadone, have a proven track record when it comes to these goals. We should see opioid use disorder as a chronic, relapsing disease that can be managed medically, just like other chronic diseases such as diabetes and high blood pressure. A person can live a happy and healthy life with the right treatments. Suboxone and methadone help people live happy and healthy lives, and we should examine whether our motivation to stop these medications is due to actual health concerns or is simply due to ideological factors.
Thad: Final rebuttal, Dr. Allrite.
Dr. Allrite: Suboxone and methadone are effective for treating opioid use disorder, but they are drugs, and all drugs are poisons if taken in a high enough dose or for long enough. If a person can be tapered off Suboxone successfully and safely, we should try. Many patients also prefer not to take medication for the rest of their lives, and abstinence is their personal goal. We should always prioritize patient autonomy. If a person must remain on Suboxone indefinitely, that is one thing, but that doesn’t have to be the norm for treatment.
Thad: Thank you both! There you have it, the arguments for and against the long-term use of Suboxone. Which arguments are most compelling to you? Please feel free to reach out with any thoughts or questions.
Next time on Mainline: How much fentanyl is in your children’s cand…[TRANSMISSION END]
Please note that today’s news show was fake but the question is real. Every day doctors and people with opioid use disorder face this challenge. I myself am unsure of the answer, which is why I chose this format which frames the problem as a literal debate.
If you or someone you love is suffering from problematic drug or alcohol use and interested in seeking treatment, contact my clinic, North Tampa Executive Health, to schedule a FREE discovery call and initial evaluation. You pay nothing unless you decide to start treatment. Click the “Get Started” button to schedule your FREE call today!
