Effects of Suboxone on People Who Use Fentanyl
Understanding Fentanyl and Its Effects
To comprehend the impact of Suboxone on people who use fentanyl, it's crucial to first understand what fentanyl is and the effects it can have on the human body.
Potency of Fentanyl
Fentanyl is a synthetic opioid that is approximately 100 times more potent than morphine. It's often mixed with other illicit drugs to increase their potency. This potent substance is sold in various forms, including powders, nasal sprays, and counterfeit pills. Drug dealers have been known to mix fentanyl with drugs like heroin, methamphetamine, and cocaine, which greatly heightens the risk of a fatal interaction due to fentanyl's high potency.
One alarming aspect of illicitly produced fentanyl is its inconsistency in dosage. Counterfeit pills have been found to contain lethal doses of fentanyl, ranging from .02 to 5.1 milligrams per tablet [1].
Effects of Fentanyl Use
The consumption of fentanyl produces effects similar to other opioids. These include euphoria, pain relief, relaxation, sedation, confusion, drowsiness, dizziness, nausea, vomiting, urinary retention, and pupillary constriction [1].
However, the excessive potency of fentanyl also means that its negative effects are significantly more dangerous. Overdosing on fentanyl can lead to symptoms such as stupor, changes in pupillary size, cold and clammy skin, cyanosis (blue discoloration of the skin), respiratory failure, coma, and in severe cases, death.
Understanding the potency and effects of fentanyl sets the stage for exploring how Suboxone can intervene in fentanyl consumption, potentially mitigating these harmful effects. It underscores the urgency and importance of effective treatment options for those struggling with fentanyl use.
Introduction to Suboxone
Suboxone is a medication primarily used in the treatment of opioid use disorder, particularly for individuals who use fentanyl. Understanding the composition and mechanism of its action is integral to fully appreciating the effects of Suboxone on people who use fentanyl.
Composition of Suboxone
Suboxone is a co-formulation of two active ingredients: buprenorphine and naloxone. Buprenorphine is a synthetic opioid that was developed in the late 1960s and is used to treat both acute and chronic pain, as well as opioid dependence. It is approved by the U.S. Food and Drug Administration (FDA) for these purposes and is used in agonist substitution treatment to address addiction. This is achieved by substituting more potent opioids with buprenorphine or methadone.
The second ingredient, naloxone, is an opioid antagonist. The purpose of combining naloxone with buprenorphine is to decrease the likelihood of abuse or diversion of the medication. This is particularly important for patients with co-occurring HIV/AIDS and opioid dependence, as they represent a significant risk for personal harm and harm to others if they relapse to opioid use and continue high-risk injection drug use and sexual practices [3].
Mechanism of Action
The mechanism of action of Suboxone lies primarily in the properties of its main active ingredient, buprenorphine. Buprenorphine is a long-acting, high-affinity partial agonist at the mu-opioid receptor. This means that it binds strongly to these receptors and partially stimulates them. This stimulation is sufficient to prevent withdrawal and craving, stabilize opioid receptors, block other opioids from binding, and has a low overdose risk with no intoxication in opioid-dependent individuals.
Buprenorphine's partial agonist action results in a slow onset of action and a "ceiling effect" where dose-related side effects plateau. This reduces the risk of overdose compared to other opioids. Buprenorphine also acts as a weak kappa receptor antagonist and delta receptor agonist. It exhibits high-affinity binding to mu-opioid receptors and slow-dissociation kinetics, resulting in milder and less uncomfortable withdrawal symptoms compared to full-opioid agonists like morphine and fentanyl [2].
In summary, Suboxone's unique composition and mechanism of action make it an effective medication for individuals who use fentanyl, providing relief from withdrawal and cravings while minimizing the potential for abuse and overdose.
Suboxone Treatment for Fentanyl Users
Treatment of fentanyl users presents unique challenges due to the potency of fentanyl. However, Suboxone, a formulation of buprenorphine, has shown promise in managing opioid dependence, including fentanyl.
Efficacy of Suboxone
Buprenorphine, specifically in the form of Suboxone, is recommended as the treatment of choice for opioid-dependent individuals. Notably, it has been favored for opioid-dependent pregnant women due to it being safer than methadone or medical withdrawal, causing fewer neonatal withdrawal symptoms, higher birth weight, and lesser preterm birth [4].
Buprenorphine works by displacing other opioids without creating an equal opioid effect, leading to "precipitated withdrawal" characterized by a rapid and intense onset of withdrawal symptoms. To avoid distress, individuals must be in a state of mild to moderate withdrawal before starting therapy with buprenorphine.
However, caution is advised when using buprenorphine in patients with compromised respiratory function, as it has been associated with life-threatening respiratory depression and death, especially when misused or in combination with other CNS depressants [5].
Comparison with Methadone
When comparing Suboxone with methadone, studies have shown similar efficacy when treatment conditions are similar. This is particularly true for patients who take higher doses of Suboxone. It was observed that methadone was associated with better treatment retention and more negative urine drug tests than buprenorphine, but it was hypothesized that this was due to underdosing of buprenorphine in early studies.
Buprenorphine, like methadone, is used in agonist substitution treatment to address addiction. This approach involves substituting more potent full agonist opioids, such as heroin or fentanyl, with less potent opioids like buprenorphine or methadone. This allows patients to withdraw from opiate addiction with minimal discomfort and reduces morbidity and mortality rates by mitigating distressing symptoms associated with opioid withdrawal.
In conclusion, while both Suboxone and methadone have their roles in treating fentanyl users, the choice of treatment depends on individual patient characteristics and needs. Regardless of the chosen treatment, the ultimate goal is to help patients manage their opioid dependency and lead healthier, more fulfilling lives.
Considerations for Suboxone Treatment
When considering Suboxone treatment for fentanyl users, there are several important factors to take into account. These include the recommended dosage of Suboxone and how the dominance of fentanyl in the drug supply can impact its effectiveness.
Dosage Recommendations
Suboxone treatment dosage is a critical consideration for its effectiveness. A study published by JAMA Network Open indicates that patients prescribed the standard daily dose of buprenorphine (16 mg) were at a significantly higher risk of discontinuing treatment within 180 days, compared to those prescribed a higher dose (24 mg).
Interestingly, during the study period from 2016 to 2020, nearly five times as many patients with opioid use disorder (OUD) were initially prescribed a daily dose of 16 mg of buprenorphine compared to 24 mg, despite the latter being associated with improved treatment retention.
This data suggests that higher buprenorphine doses than currently recommended may be beneficial for improving retention in treatment.
Impact of Fentanyl Dominance
The predominance of fentanyl in the drug supply can also impact the effectiveness of Suboxone treatment. The same JAMA Network Open study suggests that future research should explore whether the prevalence of fentanyl may necessitate higher buprenorphine doses for the treatment of OUD. This challenges the current FDA-recommended dose of 16 mg and suggests that higher dosages might be more beneficial in the context of widespread fentanyl availability.
In conclusion, understanding the effects of Suboxone on people who use fentanyl involves careful consideration of dosage recommendations and the impact of fentanyl dominance. It's essential to monitor these factors to optimize Suboxone treatment and improve its effectiveness in managing opioid use disorder.
Optimizing Suboxone Treatment
The road to recovery from fentanyl use can be a challenging one. However, treatments such as Suboxone have shown promising results in aiding this journey. The effects of Suboxone on people who use fentanyl can be optimized by focusing on two key areas: the benefits of higher doses and the importance of retention in treatment.
Higher Dose Benefits
According to a cohort study of patients initiating buprenorphine treatment from 2016 to 2020, patients who were prescribed a 24 mg dose of buprenorphine were more likely to remain in treatment than those prescribed 16 mg. This suggests that higher buprenorphine doses than currently recommended may be beneficial for improving retention in treatment.
During the same study period, nearly five times as many patients with opioid use disorder (OUD) were initially prescribed a buprenorphine daily dose of 16 mg compared to 24 mg. However, those prescribed the higher dose were 20% more likely to be retained in treatment over 180 days.
Figures derived from JAMA Network Open
Retention in Treatment
Retention in treatment is a crucial aspect of recovery from fentanyl use. The study findings suggest that patients prescribed the recommended daily dose of buprenorphine (16 mg) were at significantly greater risk of treatment discontinuation within 180 days compared to those prescribed a higher dose (24 mg).
Moreover, the study results suggest that future research should explore whether fentanyl predominance in the drug supply may be associated with increases in the optimal buprenorphine dose for the treatment of opioid use disorder (OUD), and that a higher dose may now improve retention in treatment.
By focusing on these two areas, healthcare providers can help optimize the effects of Suboxone on people who use fentanyl, ultimately contributing to better treatment outcomes for those struggling with opioid use disorder.
Future Perspectives
As we continue to grapple with the effects of suboxone on people who use fentanyl, it's important to consider future research directions and implications for opioid use disorder (OUD).
Research Directions
The potential of buprenorphine, a key component of Suboxone, to treat various addiction disorders beyond its established uses is currently being explored. One promising avenue of research involves an experimental formulation that combines buprenorphine and naltrexone to address cocaine addiction. This combination aims to reduce compulsive cocaine use without leading to opioid addiction.
Additionally, the impact of fentanyl predominance in the drug supply on the optimal buprenorphine dose for OUD treatment is a critical area of future research focus. This is based on study results suggesting that a higher dose might now improve retention in treatment [6].
Implications for Opioid Use Disorder
From a policy perspective, the Drug Addiction Treatment Act (DATA) of 2016 has played a vital role in allowing physicians to provide office-based treatment for opioid addiction. It permits the prescription of Schedule III, IV, or V "narcotic" medications approved by the FDA for patients with opioid addiction. Notably, in 2002, the FDA approved buprenorphine and a combination of buprenorphine-naloxone for managing opioid dependence.
Furthermore, recent changes in legislation have significant implications for the accessibility of Suboxone treatment. Before January 2023, clinicians were required to obtain a DATA waiver, commonly known as an X-waiver, to prescribe buprenorphine for treating OUD. Fortunately, the Consolidated Appropriations Act of 2023 eliminated the X-waiver requirement, enabling clinicians with Schedule III authority to prescribe buprenorphine for OUD treatment without the DATA waiver.
Such developments point to an encouraging future in which access to effective treatments like Suboxone becomes increasingly available for people struggling with opioid addiction, and the potential to leverage such treatments to address other forms of addiction is further explored. It's crucial, however, to ensure that these advancements are accompanied by robust research and patient education to maximize their efficacy and safety.
References
[1]: https://www.dea.gov/resources/facts-about-fentanyl
[2]: https://www.ncbi.nlm.nih.gov/books/NBK459126/
[3]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3334287/
[4]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855417/
[5]: https://go.drugbank.com/drugs/DB00921
[6]: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2809633