Confusion About Suboxone

There is an interesting recent article in MEDPAGE TODAY titled “Suboxone Underused, Opioids Overused in Medicine.” To me, that is an oxymoron.

As I’ll explain, the title does make sense if you’re trying to communicate to the lay public, but it is an ambiguous and seemingly contradictory statement. Since there’s already way too much confusion in the discussion of opioids, let me clarify what the MEDPAGE TODAY article most likely is trying to convey.

Suboxone is a brand name for a specific product that is used to treat addiction. It is a combination of buprenorphine and naloxone. The active ingredient to treat addiction is buprenorphine.

Buprenorphine has some different pharmacologic properties from morphine and oxycodone, but it is an opioid. Buprenorphine is often abused and is addictive. In recent years, the rate of buprenorphine abuse has exceeded that of most all other opioids.

The naloxone in Suboxone is not absorbed into the body if it is taken as directed. But the naloxone is there to prevent patients from experiencing the positive effects (pain relief and a “high”) of buprenorphine if they find a way to inject Suboxone instead of taking it as directed.

So, to say that Suboxone (which is an opioid) is underused as part of a statement that “opioids are overused” makes little sense without further explanation. I think the point the article is trying to make is that this opioid (Suboxone) is underused while other (unnamed) opioids are overused.

Perhaps it sounds as if I’m splitting hairs, but I believe it’s important to make the point. The discussion of opioids has been fraught with so much misinformation that the last thing we want is more confusion.

And it is confusing to say one opioid is underused while other opioids are overused. The article presumes that readers know, and understand, the differences in the opioids. Given the fact that opioids have become so politicized, I think it’s best to be very clear when writing about the topic.

I think the general point MEDPAGE TODAY is trying to make is that addiction is undertreated with opioids, while pain is overtreated with opioids. This would make sense to healthcare professionals who understand the disease of addiction, and who know that there are good reasons to use an opioid to treat an opioid addiction. But, to others, the statement that it is a good idea to treat opioid addiction with an opioid might seem as strange as saying that it would be reasonable to treat alcoholism with alcohol.

Suboxone vs. Buprenorphine

Another problem is that the title of the MEDPAGE TODAY article reads like an advertisement for Suboxone. Why does the title specify Suboxone? What about the other buprenorphine products?

I’m not accusing MEDPAGE TODAY of benefitting financially by pushing Suboxone. Rather, I suspect the publication uses the term only because most readers have heard of Suboxone and may not know what buprenorphine (or, for that matter, what naloxone) is.

It’s a bit like, in the old days, when we’d talk about making a “Xerox®” of something rather than a photocopy, or we’d reach for a “Kleenex®” instead of a facial tissue. It was always inappropriate to use brand names in the generic sense, but many of us carelessly used those terms as a shorthand in general conversation. That didn’t much matter unless you owned stock in one of the companies whose brand name was threatened by such misuse.

However, when readers don’t know that you’re using the brand name Suboxone in the generic sense, then you’re making a complex situation even more bewildering.

So, here’s what readers should know about Suboxone:

• Some buprenorphine products, like Suboxone, have been developed to treat opioid addiction. Other buprenorphine products have been developed to treat pain.
• Buprenorphine can be administered in various ways, and under several brand names: intravenously (Buprenex), sublingually or transmucosally (Suboxone, Buanvail, Zubsolv), or transdermally (Butrans).
• Recently, the FDA approved an implant (Probuphine) that delivers buprenorphine subcutaneously over 6 months. This product is approved for treatment of opioid addiction.
• On the other hand, Butrans and Belbuca (transmucosal) are approved to treat pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. Intravenous buprenorphine (Buprenex) is also approved to treat acute pain.
• Prescribing buprenorphine for addiction requires a special license, but it can be prescribed from a physician’s office. This is often referred to as office-based agonist therapy (OBT).

The MEDPAGE TODAY was helpful in bringing to light an issue of which patients may have been unaware. In fact, opioids can be used to treat opioid addiction. Because of complex laws, they probably are not used as frequently to treat addiction as they could be.

There’s more to say on the subject, but this seems like a good place to pause. You can read the second part of this blog next week.

Purchase my book The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us (available on Amazon) or read a free excerpt here.

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Copyright 2016, Lynn Webster, MD